Basic Information
| Provider Information | |||||||||
| NPI: | 1063739621 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLENN | ||||||||
| FirstName: | JOSPEH | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 33194 | ||||||||
| Address2: | |||||||||
| City: | FORT LEWIS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984330194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167026833 | ||||||||
| FaxNumber: | 2539683474 | ||||||||
| Practice Location | |||||||||
| Address1: | 9040 JACKSON AVE | ||||||||
| Address2: | MADIGAN ARMY MEDICAL CENTER WTB CLINIC | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984315000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852397582 | ||||||||
| FaxNumber: | 7852397364 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2010 | ||||||||
| LastUpdateDate: | 11/05/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | A02941 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LP2300X | COA 09013-NP | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.