Provider Demographics
NPI:1902886542
Name:LAWRENCE, BRIAN C (PAAA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:C
Last Name:LAWRENCE
Suffix:
Gender:M
Credentials:PAAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 551420
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33355-1420
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:954-839-2569
Practice Address - Street 1:1000 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-0000
Practice Address - Country:US
Practice Address - Phone:678-514-1991
Practice Address - Fax:678-514-1992
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003903367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100002166AMedicaid
GA100002166HMedicaid
GAP63004Medicare UPIN
GA100002166HMedicaid