Provider Demographics
NPI:1962446377
Name:STLAWRENCE, MARK T (PA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:STLAWRENCE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:7751 BYAMEADOWS RD E
Practice Address - Street 2:SUITE H
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-5836
Practice Address - Country:US
Practice Address - Phone:904-425-6963
Practice Address - Fax:904-674-0155
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103599363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0R4EOtherBCBS
FL000809800Medicaid
FLL4724OtherMEDICARE