MEDICARE: JESSE GLICK PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1194222398
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSE GLICK PA

Provider Business Mailing Address
First Line	:	86 RUN VALLEY RD
Second Line	:
City	:	CONESTOGA
State	:	PA
Zip	:	17516-9734
Country	:	US
Telephone Number	:	717-723-0147
Fax Number	:

Provider Business Practice Location Address
First Line	:	86 RUN VALLEY RD
Second Line	:
City	:	CONESTOGA
State	:	PA
Zip	:	17516-9734
Country	:	US
Telephone Number	:	717-723-0147
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/12/2018
Last Update Date	:	04/12/2018

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Directions to “ JESSE GLICK PA” Practice Location

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