Healthcare Provider Details

I. General information

NPI: 1992782668
Provider Name (Legal Business Name): GLENN TRIPP PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 12/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9633 BITTER MELON DR
ANGIER NC
27501-5917
US

IV. Provider business mailing address

9633 BITTER MELON DR
ANGIER NC
27501-5917
US

V. Phone/Fax

Practice location:
  • Phone: 919-639-8900
  • Fax: 919-639-9500
Mailing address:
  • Phone: 919-639-8900
  • Fax: 919-639-9500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number103877
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: