Provider Demographics
NPI:1598394991
Name:GLENN, DANIEL JOHN (PA-C)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JOHN
Last Name:GLENN
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:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0328
Mailing Address - Fax:502-587-4784
Practice Address - Street 1:201 ABRAHAM FLEXNER WAY STE 100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3841
Practice Address - Country:US
Practice Address - Phone:502-587-8222
Practice Address - Fax:502-587-0860
Is Sole Proprietor?:No
Enumeration Date:2020-04-07
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC985363A00000X
KYPA2687363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300045010Medicaid
KY7100707330Medicaid