Provider Demographics
NPI:1992782668
Name:TRIPP, GLENN (PA)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:TRIPP
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:9633 BITTER MELON DR
Mailing Address - Street 2:
Mailing Address - City:ANGIER
Mailing Address - State:NC
Mailing Address - Zip Code:27501-5917
Mailing Address - Country:US
Mailing Address - Phone:919-639-8900
Mailing Address - Fax:919-639-9500
Practice Address - Street 1:9633 BITTER MELON DR
Practice Address - Street 2:
Practice Address - City:ANGIER
Practice Address - State:NC
Practice Address - Zip Code:27501-5917
Practice Address - Country:US
Practice Address - Phone:919-639-8900
Practice Address - Fax:919-639-9500
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC103877363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP99833Medicare UPIN
NC2759670AMedicare ID - Type Unspecified