Individual
LARRY WAYNE SHOCK JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
13737 NOEL ROAD, SUITE 1400, DALLAS, TX 75240-2004
(972) 715-5000
(972) 715-9976
Mailing address
PO BOX 650865, DALLAS, TX 75265-0865
(972) 715-5000
(972) 715-9976
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
786298
TX
367500000X
Certified Registered Nurse Anesthetist
Primary
786298
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200458930A
—
OK
05
—
306652401
—
TX
01
—
8476UD
BCBS PIN
TX
01
—
P01102917
RAILROAD MEDICARE PTAN
TX
Enumeration date
10/13/2011
Last updated
05/21/2014
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