Basic Information
| Provider Information | |||||||||
| NPI: | 1013211937 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLASSICK | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | RYAN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 570 STERNWHEEL DR | ||||||||
| Address2: | |||||||||
| City: | ST JOHNS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322598662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5404604236 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12303 SAN JOSE BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322232640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042880277 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2011 | ||||||||
| LastUpdateDate: | 08/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9105842 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 022420 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 003323800 | 05 | FL | MEDICAID |