Provider Demographics
NPI:1831625862
Name:DESHAZER, RAYMOND DALE (ATP)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:DALE
Last Name:DESHAZER
Suffix:
Gender:M
Credentials:ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 RED HAWK BAY DR
Mailing Address - Street 2:
Mailing Address - City:WEST TAWAKONI
Mailing Address - State:TX
Mailing Address - Zip Code:75474-4530
Mailing Address - Country:US
Mailing Address - Phone:469-877-8113
Mailing Address - Fax:214-677-0157
Practice Address - Street 1:2001 108TH ST
Practice Address - Street 2:STE 104
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-1437
Practice Address - Country:US
Practice Address - Phone:214-677-0186
Practice Address - Fax:214-677-0157
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXATP88264247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other