Healthcare Provider Details

I. General information

NPI: 1780213553
Provider Name (Legal Business Name): CIARA GLENN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

3635 VISTA AVE
SAINT LOUIS MO
63110-2539
US

V. Phone/Fax

Practice location:
  • Phone: 314-257-3390
  • Fax: 314-617-2113
Mailing address:
  • Phone: 314-577-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number085008403
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2021009905
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: