Provider Demographics
NPI:1497931810
Name:DEWITTE, LAWRENCE S (PA)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:S
Last Name:DEWITTE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 TUSCULUM BLVD
Mailing Address - Street 2:SUITE 2500
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37745-5821
Mailing Address - Country:US
Mailing Address - Phone:423-638-1291
Mailing Address - Fax:423-638-9398
Practice Address - Street 1:1410 TUSCULUM BLVD
Practice Address - Street 2:SUITE 2500
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-5821
Practice Address - Country:US
Practice Address - Phone:423-638-1291
Practice Address - Fax:423-638-9398
Is Sole Proprietor?:No
Enumeration Date:2008-01-16
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9103020363AM0700X
TN2326363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLR18947Medicare UPIN