Basic Information
| Provider Information | |||||||||
| NPI: | 1306882147 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLASS | ||||||||
| FirstName: | GRAHAM | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 NE PARK PLAZA DR | ||||||||
| Address2: | SIUTE 100 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986845895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602548025 | ||||||||
| FaxNumber: | 3602548618 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 NE PARK PLAZA DR | ||||||||
| Address2: | SIUTE 100 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986845895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602548025 | ||||||||
| FaxNumber: | 3602548618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 06/24/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD00037803 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110187987 | 01 | WA | RAILROAD MEDICARE | OTHER | 8244923 | 05 | WA | MEDICAID |