Provider Demographics
NPI:1225209240
Name:BROCK, BRANDON RAYMOND (CRNA)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:RAYMOND
Last Name:BROCK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 BRAZOS DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6027
Mailing Address - Country:US
Mailing Address - Phone:225-610-2051
Mailing Address - Fax:
Practice Address - Street 1:1011 BRAZOS DR
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6027
Practice Address - Country:US
Practice Address - Phone:225-610-2051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-18
Last Update Date:2016-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA094793367500000X
TXAP123128367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered