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General NPI Number Information
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NPI Number | 1104996610
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Entity Type | Individual
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Provider Name | LARRY GLEN ANDREW D.O.
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Gender | Male
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Dates
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Enumeration Date | 11/09/2006
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Last Update Date | 07/03/2013
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Provider Practice Location Address
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Address Line | 746 E 1910 S STE 1
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City | PROVO
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State | UT
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Zip | 84606-6227
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Country | US
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Telephone | 801-377-0580
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Fax | 801-375-5582
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Provider Business Mailing Address
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Address Line | 746 E 1910 S STE 1
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City | PROVO
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State | UT
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Zip | 84606-6227
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Country | US
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Telephone | 801-377-0580
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Fax | 801-375-5582
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 326767-1204
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License Number State | UT
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