Provider Demographics
NPI:1578232815
Name:LAWRENCE, MAXFIELD ROY (PA-C)
Entity Type:Individual
Prefix:
First Name:MAXFIELD
Middle Name:ROY
Last Name:LAWRENCE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-8748
Mailing Address - Fax:
Practice Address - Street 1:1118 NW 16TH ST STE D
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2272
Practice Address - Country:US
Practice Address - Phone:208-452-7677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-12-13
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant