Provider Demographics
NPI:1346278520
Name:ELLIOTT, LAWRENCE CRAIG (PA-C)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:CRAIG
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:PA-C
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 843145
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-3145
Mailing Address - Country:US
Mailing Address - Phone:910-974-7555
Mailing Address - Fax:910-974-4555
Practice Address - Street 1:21O E MAIN ST.
Practice Address - Street 2:
Practice Address - City:CANDOR
Practice Address - State:NC
Practice Address - Zip Code:27229-8088
Practice Address - Country:US
Practice Address - Phone:910-974-7555
Practice Address - Fax:910-974-4555
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101376363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCFH4000420OtherFIRST CAROLINA CARE
NCD0491OtherMEDCOST
NC970018704OtherR R MEDICARE
NC2743006BMedicare ID - Type Unspecified
NC970018704OtherR R MEDICARE