Provider Demographics
NPI:1972589695
Name:LAWSON, MARK ALLAN (PA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALLAN
Last Name:LAWSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:550 POPE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66027-2332
Mailing Address - Country:US
Mailing Address - Phone:913-758-3793
Mailing Address - Fax:
Practice Address - Street 1:550 POPE AVE
Practice Address - Street 2:
Practice Address - City:FORT LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66027-2332
Practice Address - Country:US
Practice Address - Phone:913-758-3793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01189363A00000X
1053751363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1053751OtherNCCPA
KS15-01189OtherSTATE PA LICENSE