Provider Demographics
NPI:1972513364
Name:GLOVER, DALE BEAIRD (PA-C)
Entity type:Individual
Prefix:MR
First Name:DALE
Middle Name:BEAIRD
Last Name:GLOVER
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:CRESCENT CITY PHYSICIANS, INC.
Mailing Address - Street 2:3600 PRYTANIA ST., STE. 35
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70115-3678
Mailing Address - Country:US
Mailing Address - Phone:504-897-7197
Mailing Address - Fax:504-249-5311
Practice Address - Street 1:1401 FOUCHER ST FL 5
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115-3515
Practice Address - Country:US
Practice Address - Phone:504-897-7999
Practice Address - Fax:504-897-7676
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04743363A00000X
LA200155363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2131991Medicaid