Provider Demographics
NPI:1033803481
Name:GLASS, STACIE (PA)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:GLASS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:395 W COUGAR BLVD STE 602
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3331
Mailing Address - Country:US
Mailing Address - Phone:801-357-0570
Mailing Address - Fax:
Practice Address - Street 1:395 W COUGAR BLVD STE 602
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3331
Practice Address - Country:US
Practice Address - Phone:801-357-0570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-07
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant