Provider Demographics
NPI:1740767987
Name:LAWSON, BRYANT
Entity Type:Individual
Prefix:
First Name:BRYANT
Middle Name:
Last Name:LAWSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2266 SAINT PAUL RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERTON
Mailing Address - State:SC
Mailing Address - Zip Code:29148-7021
Mailing Address - Country:US
Mailing Address - Phone:803-732-3518
Mailing Address - Fax:
Practice Address - Street 1:2266 SAINT PAUL RD
Practice Address - Street 2:
Practice Address - City:SUMMERTON
Practice Address - State:SC
Practice Address - Zip Code:29148-7021
Practice Address - Country:US
Practice Address - Phone:803-732-3518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC172A00000X
172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver