Provider Demographics
NPI:1043319676
Name:GLENN, JOHN KENNETH (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:KENNETH
Last Name:GLENN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 FRANKLIN ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-2899
Mailing Address - Country:US
Mailing Address - Phone:360-213-1301
Mailing Address - Fax:
Practice Address - Street 1:2460 NE GRIFFIN OAKS ST
Practice Address - Street 2:SUITE D1000
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-2672
Practice Address - Country:US
Practice Address - Phone:360-213-1301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003835363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical