Provider Demographics
NPI:1346248150
Name:PARK, LAURA H (CRNA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:H
Last Name:PARK
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 11219
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-0219
Mailing Address - Country:US
Mailing Address - Phone:817-294-7444
Mailing Address - Fax:
Practice Address - Street 1:6405 W PARKER RD
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-8179
Practice Address - Country:US
Practice Address - Phone:972-473-9292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX653370367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX167837701Medicaid
TX167837704Medicaid
TX85706UOtherBCBS-TX
TX84235UOtherBLUE CROSS BLUE SHIELD
TX84235UOtherBLUE CROSS BLUE SHIELD
TXQ23216Medicare UPIN