Provider Demographics
NPI:1992493340
Name:LAWRENCE, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:LAWRENCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4545 N 67TH AVE UNIT 1176
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85033-1677
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4545 N. 67TH AVE.
Practice Address - Street 2:UNIT 1176
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033
Practice Address - Country:US
Practice Address - Phone:928-504-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ227837363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health