Basic Information
| Provider Information | |||||||||
| NPI: | 1023410461 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLOSE | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 325 ESSJAY RD | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142218243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166312517 | ||||||||
| FaxNumber: | 7166345650 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 ESSJAY RD STE 170 | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142218243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166312517 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2014 | ||||||||
| LastUpdateDate: | 02/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 017985 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 017985 | 01 | NY | LICENSE | OTHER |