Provider Demographics
NPI:1215664768
Name:DIDLAKE, DAVID WALTON (AG-ACNP)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:WALTON
Last Name:DIDLAKE
Suffix:
Gender:M
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2821 E PRESIDENT GEORGE BUSH HWY STE 505
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-4278
Mailing Address - Country:US
Mailing Address - Phone:214-943-1191
Mailing Address - Fax:214-599-2601
Practice Address - Street 1:2821 E PRESIDENT GEORGE BUSH HWY STE 505
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-4278
Practice Address - Country:US
Practice Address - Phone:214-943-1191
Practice Address - Fax:214-599-2601
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-04
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1074220363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty