Provider Demographics
NPI:1245207760
Name:AYCOCK, ETTA MARIE (CRNA)
Entity Type:Individual
Prefix:
First Name:ETTA
Middle Name:MARIE
Last Name:AYCOCK
Suffix:
Gender:F
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:PO BOX 650426
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0426
Mailing Address - Country:US
Mailing Address - Phone:972-715-5007
Mailing Address - Fax:972-715-5682
Practice Address - Street 1:1600 HOSPITAL PKWY
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-6913
Practice Address - Country:US
Practice Address - Phone:817-355-7800
Practice Address - Fax:817-355-7805
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX216964367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX430047353OtherRAILROAD
TX155484203Medicaid
TX81012UOtherBCBS
TX088599803Medicaid
TX8C7600Medicare PIN
TX81012UOtherBCBS
TX155484203Medicaid