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General NPI Number Information
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NPI Number | 1578501094
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Entity Type | Individual
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Provider Name | GLENN JOSEPH LYSACK PA
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Gender | Male
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Dates
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Enumeration Date | 06/04/2006
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Last Update Date | 01/16/2018
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Provider Practice Location Address
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Address Line | 5151 N 9TH AVE
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City | PENSACOLA
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State | FL
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Zip | 32504-8721
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Country | US
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Telephone | 850-416-7000
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2699
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City | PENSACOLA
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State | FL
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Zip | 32513-2699
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Country | US
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Telephone | 850-416-7000
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Fax |
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA3242
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License Number State | FL
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