Provider Demographics
NPI:1215940390
Name:TAMA, LAWRENCE ELLIS (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:ELLIS
Last Name:TAMA
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:22 WALNUT ST
Mailing Address - Street 2:LAUREL HEALTH CENTER ADMINISTRATION ATTN:MARIA SMITH
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901-1526
Mailing Address - Country:US
Mailing Address - Phone:570-723-0621
Mailing Address - Fax:570-724-1197
Practice Address - Street 1:236 E MAIN ST
Practice Address - Street 2:WESTFIELD LAUREL HEALTH CENTER
Practice Address - City:WESTFIELD
Practice Address - State:PA
Practice Address - Zip Code:16950-1607
Practice Address - Country:US
Practice Address - Phone:814-367-5911
Practice Address - Fax:814-367-2791
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
PAMD040669L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E52927Medicare UPIN
574461FEMMedicare ID - Type Unspecified