Provider Demographics
NPI:1265798805
Name:DISOTELL, ROBERT RYAN (ANP)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:RYAN
Last Name:DISOTELL
Suffix:
Gender:M
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 QUAIL LN
Mailing Address - Street 2:
Mailing Address - City:WAKE VILLAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75501-5722
Mailing Address - Country:US
Mailing Address - Phone:870-292-9960
Mailing Address - Fax:
Practice Address - Street 1:2604 SAINT MICHAEL DR STE 340
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2378
Practice Address - Country:US
Practice Address - Phone:903-614-5117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-09
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03684363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARA03684OtherLICENSE
TX1994OtherTX LICENSE