Provider Demographics
NPI:1912994252
Name:LAWRENCE, MARK ALLEN (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:LAWRENCE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:HCR 6100 BOX 30
Mailing Address - Street 2:
Mailing Address - City:TEECNOSPOS
Mailing Address - State:AZ
Mailing Address - Zip Code:86514
Mailing Address - Country:US
Mailing Address - Phone:928-656-5165
Mailing Address - Fax:928-656-5164
Practice Address - Street 1:JCT US HWY 160 & NAVAJO ROUTE 35 RED MESA
Practice Address - Street 2:
Practice Address - City:TEECNOSPOS
Practice Address - State:AZ
Practice Address - Zip Code:86514
Practice Address - Country:US
Practice Address - Phone:928-656-5165
Practice Address - Fax:928-656-5164
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1845363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM06831371Medicaid
CO09358251Medicaid
NM06831371Medicaid
S05270Medicare UPIN
CO09358251Medicaid
8HG752Medicare PIN
8HBU35Medicare PIN