Provider Demographics
NPI:1033443007
Name:ARN, GLEN RUSSEL (LMP)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:RUSSEL
Last Name:ARN
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1913 NW 7TH CT
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-6805
Mailing Address - Country:US
Mailing Address - Phone:360-521-0804
Mailing Address - Fax:
Practice Address - Street 1:2402 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-3229
Practice Address - Country:US
Practice Address - Phone:360-521-0804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-24
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023548174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist