Healthcare Provider Details

I. General information

NPI: 1578501094
Provider Name (Legal Business Name): GLENN JOSEPH LYSACK PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 FARRAGUT AVE BLDG 940
BREMERTON WA
98314-6001
US

IV. Provider business mailing address

1400 FARRAGUT AVE BLDG 940
BREMERTON WA
98314-6001
US

V. Phone/Fax

Practice location:
  • Phone: 360-476-6872
  • Fax: 360-476-6872
Mailing address:
  • Phone: 360-476-6872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3242
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: