Provider Demographics
NPI:1912492927
Name:BLACK, DANIEL LAWRENCE (MSN, FNP)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:LAWRENCE
Last Name:BLACK
Suffix:
Gender:M
Credentials:MSN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 W ERWIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-7227
Mailing Address - Country:US
Mailing Address - Phone:830-708-2135
Mailing Address - Fax:
Practice Address - Street 1:1400 W SW LOOP 323 STE 60
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-7059
Practice Address - Country:US
Practice Address - Phone:903-526-4875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-22
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP137811363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner