Provider Demographics
NPI:1104163104
Name:GLASS, MICHAEL MARKUS (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:MARKUS
Last Name:GLASS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2525 OHIO DR APT 2708
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-3012
Mailing Address - Country:US
Mailing Address - Phone:214-316-6962
Mailing Address - Fax:214-501-1334
Practice Address - Street 1:6020 W PARKER RD
Practice Address - Street 2:SUITE 430
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-8171
Practice Address - Country:US
Practice Address - Phone:214-316-6962
Practice Address - Fax:214-501-1334
Is Sole Proprietor?:No
Enumeration Date:2013-01-10
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TXPA08205363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant