Basic Information
| Provider Information | |||||||||
| NPI: | 1588717516 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAWSON | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 385 RANCH ROAD | ||||||||
| Address2: | |||||||||
| City: | REEDSPORT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412712119 | ||||||||
| FaxNumber: | 5412716344 | ||||||||
| Practice Location | |||||||||
| Address1: | 385 RANCH ROAD | ||||||||
| Address2: | |||||||||
| City: | REEDSPORT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412712119 | ||||||||
| FaxNumber: | 5412716344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2007 | ||||||||
| LastUpdateDate: | 11/23/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD18026 | OR | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 046404 | 05 | OR | MEDICAID |