Provider Demographics
NPI:1972061612
Name:GLENN, AARON DEAN
Entity type:Individual
Prefix:
First Name:AARON
Middle Name:DEAN
Last Name:GLENN
Suffix:
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 1:26136 US HIGHWAY 59
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:MO
Mailing Address - Zip Code:64446-9105
Mailing Address - Country:US
Mailing Address - Phone:660-686-2211
Mailing Address - Fax:660-686-2618
Practice Address - Street 1:26136 US HIGHWAY 59
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:MO
Practice Address - Zip Code:64446-9105
Practice Address - Country:US
Practice Address - Phone:660-686-2211
Practice Address - Fax:660-686-2618
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019007056363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner