Basic Information
Provider Information | |||||||||
NPI: | 1609089481 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOCKMON | ||||||||
FirstName: | LYNDA | ||||||||
MiddleName: | ELIZABETH | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | ANP-BC, ACNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 221 W. COLORADO BLVD | ||||||||
Address2: | PAVILION 2, SUITE 425 | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752085500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2149473231 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 910 E HOUSTON ST | ||||||||
Address2: |   | ||||||||
City: | TYLER | ||||||||
State: | TX | ||||||||
PostalCode: | 757028369 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9035257995 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/08/2007 | ||||||||
LastUpdateDate: | 08/30/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 718484 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
ID | Type | State | Issuer | Description | 189237401 | 05 | TX |   | MEDICAID | 752616977008 | 01 | TX | TRICARE | OTHER | 01951633 | 05 | NY |   | MEDICAID | 000560448001 | 01 | NY | BLUE CROSS BLUE SHIELD | OTHER | 8Y2322 | 01 | TX | BCBS | OTHER |