Provider Demographics
NPI:1720153224
Name:HILTON, LARRY S (APN)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:S
Last Name:HILTON
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 S FANNIN AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-8204
Mailing Address - Country:US
Mailing Address - Phone:903-535-9041
Mailing Address - Fax:
Practice Address - Street 1:928 N GLENWOOD BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-5055
Practice Address - Country:US
Practice Address - Phone:903-535-9041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP119371363LW0102X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45-2578435-001OtherTRICARE
TX218365902Medicaid
TXP01731680OtherRAIL ROAD MEDICARE
TX8445NYOtherBCBS
IL209005944Medicaid
TX45-2578435OtherTRICARE
TX45-2578435-004OtherTRICARE
TX45-2578435-002OtherTRICARE
TX45-2578435OtherTRICARE
ILK32951Medicare PIN