Provider Demographics
NPI:1992928477
Name:BAILEY, GLENN CHARLES JR (PA-C)
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:CHARLES
Last Name:BAILEY
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:3300 GALLOWS RD
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-3307
Mailing Address - Country:US
Mailing Address - Phone:703-776-1110
Mailing Address - Fax:703-776-2897
Practice Address - Street 1:3300 GALLOWS RD
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-3307
Practice Address - Country:US
Practice Address - Phone:703-776-3669
Practice Address - Fax:703-776-2897
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-00118363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1992928477Medicare PIN