Healthcare Provider Details

I. General information

NPI: 1356395818
Provider Name (Legal Business Name): LORI D MOCK-BLAIR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LORI D MOCK PA-C

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 CYPRESS CREEK RD STE 100
CEDAR PARK TX
78613-3925
US

IV. Provider business mailing address

4700 EXCHANGE CT STE 110
BOCA RATON FL
33431-4450
US

V. Phone/Fax

Practice location:
  • Phone: 877-345-5300
  • Fax: 561-989-3665
Mailing address:
  • Phone: 877-345-5300
  • Fax: 561-989-3665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA200543
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA03107
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: