Healthcare Provider Details

I. General information

NPI: 1497973325
Provider Name (Legal Business Name): PAUL V MCGLYNN JR. P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 04/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49TH MEDICAL GROUP/SGOPF 280 FIRST STREET, BLDG 23
HOLLOMAN AFB NM
88330-8273
US

IV. Provider business mailing address

49TH MEDICAL GROUP/SGOPF 280 FIRST STREET, BLDG 23
HOLLOMAN AFB NM
88330-8273
US

V. Phone/Fax

Practice location:
  • Phone: 575-572-7091
  • Fax: 575-572-2259
Mailing address:
  • Phone: 575-572-7091
  • Fax: 575-572-2259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number002538
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: