Provider Demographics
NPI:1417974007
Name:LAWRENCE, STEPHANIE L (PA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-740-8400
Mailing Address - Fax:817-924-5144
Practice Address - Street 1:1250 8TH AVE
Practice Address - Street 2:SUITE 435
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4124
Practice Address - Country:US
Practice Address - Phone:817-923-0088
Practice Address - Fax:817-924-5144
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03195363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX181583905Medicaid
970030568OtherRAILROAD MEDICARE