Provider Demographics
NPI:1003219304
Name:GLASS, CHARLES C (PA-C)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:C
Last Name:GLASS
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:2200 SW 6TH AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66606-1707
Mailing Address - Country:US
Mailing Address - Phone:785-354-8518
Mailing Address - Fax:785-354-1255
Practice Address - Street 1:3550 S 4TH ST STE 250
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-5061
Practice Address - Country:US
Practice Address - Phone:913-565-2569
Practice Address - Fax:913-565-2571
Is Sole Proprietor?:No
Enumeration Date:2014-09-30
Last Update Date:2021-07-08
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Provider Licenses
StateLicense IDTaxonomies
MO2015022139363A00000X
KS15-01742363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant