Provider Demographics
NPI:1194711465
Name:GLINES, DAVID P (PA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:P
Last Name:GLINES
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:43800 GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1136
Mailing Address - Country:US
Mailing Address - Phone:800-848-0202
Mailing Address - Fax:586-226-6949
Practice Address - Street 1:22151 MOROSS RD
Practice Address - Street 2:313
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2167
Practice Address - Country:US
Practice Address - Phone:313-343-3494
Practice Address - Fax:313-343-4932
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2024-08-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601002117363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
N94940002Medicare ID - Type Unspecified
S14922Medicare UPIN