Provider Demographics
NPI:1265717904
Name:SHOCK, LARRY WAYNE JR (CRNA)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:WAYNE
Last Name:SHOCK
Suffix:JR
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:PO BOX 650865
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0865
Mailing Address - Country:US
Mailing Address - Phone:972-715-5000
Mailing Address - Fax:972-715-9976
Practice Address - Street 1:13737 NOEL ROAD
Practice Address - Street 2:SUITE 1400
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-2004
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:972-715-9976
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX786298163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01102917OtherRAILROAD MEDICARE PTAN
OK200458930AMedicaid
TX8476UDOtherBCBS PIN
TX306652401Medicaid
TX306652401Medicaid
OK200458930AMedicaid