Provider Demographics
NPI:1790844793
Name:BROCK, RICHARD JOHN (CRNA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JOHN
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 1:1817 BURNING TREE LN
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-2817
Mailing Address - Country:US
Mailing Address - Phone:972-276-6100
Mailing Address - Fax:972-276-1231
Practice Address - Street 1:700 WALTER REED BLVD
Practice Address - Street 2:SUITE 305
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042-3701
Practice Address - Country:US
Practice Address - Phone:972-276-6100
Practice Address - Fax:972-276-1231
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX512613367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX002831802Medicaid
TX470862522OtherTAX ID
TXS28032OtherUPIN
TX470862522OtherTAX ID