Provider Demographics
NPI:1063457653
Name:GLASER, RANDALL N (PA)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:N
Last Name:GLASER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 12TH AVE N STE 140W
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-7507
Mailing Address - Country:US
Mailing Address - Phone:406-237-5050
Mailing Address - Fax:406-238-6599
Practice Address - Street 1:2900 12TH AVE N STE 140W
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-7507
Practice Address - Country:US
Practice Address - Phone:406-237-5050
Practice Address - Fax:406-238-6599
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT321363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0439705Medicaid
MT0439705Medicaid