=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265798805
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT RYAN DISOTELL ANP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2012
-----------------------------------------------------
Last Update Date | 04/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2604 SAINT MICHAEL DR STE 340
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75503-2378
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-614-5117
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 202 QUAIL LN
-----------------------------------------------------
City | WAKE VILLAGE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75501-5722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-292-9960
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | A03684
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------