Healthcare Provider Details

I. General information

NPI: 1063739621
Provider Name (Legal Business Name): JOSPEH W GLENN NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2010
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE MADIGAN ARMY MEDICAL CENTER WTB CLINIC
TACOMA WA
98431-5000
US

IV. Provider business mailing address

PO BOX 33194
FORT LEWIS WA
98433-0194
US

V. Phone/Fax

Practice location:
  • Phone: 785-239-7582
  • Fax: 785-239-7364
Mailing address:
  • Phone: 216-702-6833
  • Fax: 253-968-3474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberA02941
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberCOA 09013-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: