Provider Demographics
NPI:1376505651
Name:LAWRENCE, BRADFORD W (PA-C)
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:W
Last Name:LAWRENCE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 509
Mailing Address - Street 2:
Mailing Address - City:SYLVA
Mailing Address - State:NC
Mailing Address - Zip Code:28779-0509
Mailing Address - Country:US
Mailing Address - Phone:828-339-7268
Mailing Address - Fax:828-586-8209
Practice Address - Street 1:5045 HICKORY BLVD
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-8920
Practice Address - Country:US
Practice Address - Phone:828-212-1020
Practice Address - Fax:828-212-1024
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC101975363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC155KEOtherBCBS NC
NC155KEOtherBCBS NC
NC2759863BMedicare PIN