Healthcare Provider Details

I. General information

NPI: 1205011475
Provider Name (Legal Business Name): GLENN ERIC GIFFORD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2008
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 LAWS AVE
UKIAH CA
95482-6540
US

IV. Provider business mailing address

333 LAWS AVE
UKIAH CA
95482-6540
US

V. Phone/Fax

Practice location:
  • Phone: 707-468-1010
  • Fax: 707-462-7532
Mailing address:
  • Phone: 707-468-1010
  • Fax: 707-462-7532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA053012
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number61224
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: