Provider Demographics
NPI:1851051833
Name:FRIERSON, AKINKAWON TAHIR (LABORATORY DIRECTOR)
Entity Type:Individual
Prefix:
First Name:AKINKAWON
Middle Name:TAHIR
Last Name:FRIERSON
Suffix:
Gender:M
Credentials:LABORATORY DIRECTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2744 US 1 S
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-6366
Mailing Address - Country:US
Mailing Address - Phone:888-890-1054
Mailing Address - Fax:904-600-4583
Practice Address - Street 1:2744 US 1 S
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-6366
Practice Address - Country:US
Practice Address - Phone:888-890-1054
Practice Address - Fax:904-600-4583
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-18
Last Update Date:2022-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10D2240563OtherCLINICAL LABORATORY IMPROVEMENT AMENDMENTS CERTIFICATE OF WAIVER