Healthcare Provider Details

I. General information

NPI: 1023410461
Provider Name (Legal Business Name): HEATHER GLOSE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2014
Last Update Date: 02/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 ESSJAY RD STE 170
WILLIAMSVILLE NY
14221-8243
US

IV. Provider business mailing address

325 ESSJAY RD
WILLIAMSVILLE NY
14221-8243
US

V. Phone/Fax

Practice location:
  • Phone: 716-631-2517
  • Fax:
Mailing address:
  • Phone: 716-631-2517
  • Fax: 716-634-5650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number017985
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: