Provider Demographics
NPI:1780731828
Name:LAWRENCE, JANICE (PAC)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 642117
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-8117
Mailing Address - Country:US
Mailing Address - Phone:402-717-4377
Mailing Address - Fax:
Practice Address - Street 1:110 N MAIN ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:IA
Practice Address - Zip Code:51560-4181
Practice Address - Country:US
Practice Address - Phone:712-482-6484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA881363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R03186Medicare UPIN
41457Medicare ID - Type Unspecified