Healthcare Provider Details

I. General information

NPI: 1447235155
Provider Name (Legal Business Name): NICOLE S GLASER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 12/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2516 STOCKTON BLVD TICON II
SACRAMENTO CA
95817-2208
US

IV. Provider business mailing address

2516 STOCKTON BLVD TICON II
SACRAMENTO CA
95817-2208
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-0406
  • Fax: 916-734-7070
Mailing address:
  • Phone: 916-734-0406
  • Fax: 916-734-7070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberG 77306
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: