Basic Information
| Provider Information | |||||||||
| NPI: | 1598836900 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAWSON | ||||||||
| FirstName: | GLENNIS | ||||||||
| MiddleName: | DARRELL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MSN-CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12752 KINGSTON PIKE | ||||||||
| Address2: | STE E202 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379340948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8657770909 | ||||||||
| FaxNumber: | 8657770910 | ||||||||
| Practice Location | |||||||||
| Address1: | 919 E. CENTRAL AVENUE | ||||||||
| Address2: | |||||||||
| City: | LAFOLLETTE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377662055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8657770909 | ||||||||
| FaxNumber: | 8657770910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2006 | ||||||||
| LastUpdateDate: | 03/22/2016 | ||||||||
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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 | 367500000X | APN11154 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 128612 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 11154 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1506017 | 05 | TN | MEDICAID | 74010061 | 05 | KY | MEDICAID | 4178543 | 01 | TN | BLUE CROSS/BLUE SHIELD | OTHER | 74010661 | 05 | KY | MEDICAID | P00632153 | 01 | RAILROAD MEDICARE | OTHER | 4110437 | 01 | TN | IND BC PROVIDER NUMBER | OTHER |