Provider Demographics
NPI:1922030816
Name:LAWRENCE, DALE H (PA)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:H
Last Name:LAWRENCE
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 1:506 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HERKIMER
Mailing Address - State:NY
Mailing Address - Zip Code:13350-1128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 MCCLELLAN ST
Practice Address - Street 2:@ ST. CLARE'S HOSPITAL ER DEPT.
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12304-1009
Practice Address - Country:US
Practice Address - Phone:518-383-5450
Practice Address - Fax:518-383-4223
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003249-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02405190Medicaid
NY02405190Medicaid