Healthcare Provider Details

I. General information

NPI: 1477543379
Provider Name (Legal Business Name): RAIMUND R GLOSSON PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

576 JEFFERSON AVE
FORT EUSTIS VA
23604-1602
US

IV. Provider business mailing address

104 YORK LN
YORKTOWN VA
23692-4029
US

V. Phone/Fax

Practice location:
  • Phone: 757-314-7595
  • Fax: 757-314-7601
Mailing address:
  • Phone: 757-890-2710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0110001204
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: