Basic Information
| Provider Information | |||||||||
| NPI: | 1174557714 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLENNON | ||||||||
| FirstName: | MARGARET | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GLENNON | ||||||||
| OtherFirstName: | BETSY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1500 CURVE CREST BLVD W | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550826040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514391234 | ||||||||
| FaxNumber: | 6512753325 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 CURVE CREST BLVD W | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550826040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514391234 | ||||||||
| FaxNumber: | 6512753325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2369-023 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 9387 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 150076 | 01 | MN | UCARE | OTHER | 561250047 | 01 | WI | MEDICARE | OTHER | 2251248 | 01 | MN | ARAZ | OTHER | 1031503 | 01 | MN | PREFERRED ONE | OTHER | 4306653 | 05 | MT | MEDICAID | HP48571 | 01 | MN | HEALTHPARTNERS | OTHER | 01-22013 | 01 | MN | MEDICA CHOICE | OTHER | 01-14853 | 01 | MN | MEDICA PRIMARY | OTHER | 711T0GL | 01 | MN | BCBS | OTHER | 55411070 | 05 | MN | MEDICAID |