Provider Demographics
NPI:1386622546
Name:GLASS, GEORDIE MCGILL (PA-C)
Entity type:Individual
Prefix:MR
First Name:GEORDIE
Middle Name:MCGILL
Last Name:GLASS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19020 33RD AVE W STE 210
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4748
Mailing Address - Country:US
Mailing Address - Phone:425-563-1500
Mailing Address - Fax:425-563-1374
Practice Address - Street 1:19020 33RD AVE W STE 210
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-4748
Practice Address - Country:US
Practice Address - Phone:425-563-1500
Practice Address - Fax:425-563-1501
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004792363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA193752OtherL&I PROVIDER NUMBER
WA266643OtherLNI PROVIDER ID
WA8418089Medicaid
WA00039587OtherLABOR AND INDUSTRIES #
WA4320GLOtherBLUE SHIELD #
WAG8883661Medicare PIN
WA193752OtherL&I PROVIDER NUMBER
WA8418089Medicaid
WA8852524Medicare PIN
WAG8895968Medicare PIN
WA266643OtherLNI PROVIDER ID
WAP00337240Medicare PIN