Provider Demographics
NPI:1407017858
Name:LAURA PARK, CRNA, PC
Entity Type:Organization
Organization Name:LAURA PARK, CRNA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CECE
Authorized Official - Middle Name:J
Authorized Official - Last Name:PANNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-294-7444
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX653370367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00C70TOtherBCBSTX
TX00C70TOtherBCBSTX