Healthcare Provider Details

I. General information

NPI: 1396176202
Provider Name (Legal Business Name): BRIAN GLASS FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2013
Last Update Date: 05/05/2024
Certification Date: 05/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20601 W. PAOLI LANE
WEIMAR CA
95736
US

IV. Provider business mailing address

515 E WASHINGTON BLVD
CRESCENT CITY CA
95531-8342
US

V. Phone/Fax

Practice location:
  • Phone: 559-797-0232
  • Fax:
Mailing address:
  • Phone: 707-460-1802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95005781
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: