Basic Information
| Provider Information | |||||||||
| NPI: | 1003261512 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOTSENBOCKER | ||||||||
| FirstName: | DARYL | ||||||||
| MiddleName: | KEITH | ||||||||
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| Credential: | AG-ACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1113 PIN OAK DR | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762094624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9407658987 | ||||||||
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| Practice Location | |||||||||
| Address1: | 221 W COLORADO BLVD | ||||||||
| Address2: | PAVILLION 2, SUITE 929 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752082363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149605681 | ||||||||
| FaxNumber: | 2149472727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2016 | ||||||||
| LastUpdateDate: | 05/03/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 754742 | TX | N | Nursing Service Providers | Registered Nurse | 363LA2100X | AP130775 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.