Basic Information
| Provider Information | |||||||||
| NPI: | 1831625862 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESHAZER | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | DALE | ||||||||
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| Credential: | ATP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 RED HAWK BAY DR | ||||||||
| Address2: | |||||||||
| City: | WEST TAWAKONI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754744530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4698778113 | ||||||||
| FaxNumber: | 2146770157 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 108TH ST | ||||||||
| Address2: | STE 104 | ||||||||
| City: | GRAND PRAIRIE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750501437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146770186 | ||||||||
| FaxNumber: | 2146770157 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2017 | ||||||||
| LastUpdateDate: | 05/11/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | ATP88264 | TX | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Other |
No ID Information.