Provider Demographics
NPI:1306314752
Name:WARE, GLEN JR
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:WARE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 OLD SOUTH FORK RD
Mailing Address - Street 2:
Mailing Address - City:KINGS MOUNTAIN
Mailing Address - State:KY
Mailing Address - Zip Code:40442-9702
Mailing Address - Country:US
Mailing Address - Phone:606-448-0693
Mailing Address - Fax:
Practice Address - Street 1:24 OLD SOUTH FORK RD
Practice Address - Street 2:
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:KY
Practice Address - Zip Code:40442-9702
Practice Address - Country:US
Practice Address - Phone:606-448-0693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-04
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012813363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily