Provider Demographics
NPI:1386972016
Name:GLASER, BETHANY L (PA-C)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:L
Last Name:GLASER
Suffix:
Gender:F
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 1:834 N SEMINARY ST
Mailing Address - Street 2:SUITE 402
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-2852
Mailing Address - Country:US
Mailing Address - Phone:309-343-5117
Mailing Address - Fax:309-343-0029
Practice Address - Street 1:834 N SEMINARY ST
Practice Address - Street 2:SUITE 402
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2852
Practice Address - Country:US
Practice Address - Phone:309-343-5117
Practice Address - Fax:309-343-0029
Is Sole Proprietor?:No
Enumeration Date:2009-11-18
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003660363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant