Provider Demographics
NPI:1093050098
Name:GLASS, CLINTON EARL SR (PA)
Entity Type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:EARL
Last Name:GLASS
Suffix:SR
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 1:51 DEAK DR
Mailing Address - Street 2:SUITE 1 FIRST FL.
Mailing Address - City:SMYRNA
Mailing Address - State:DE
Mailing Address - Zip Code:19977-1268
Mailing Address - Country:US
Mailing Address - Phone:302-653-1281
Mailing Address - Fax:302-653-1283
Practice Address - Street 1:51 DEAK DR
Practice Address - Street 2:SUITE 1 FIRST FL.
Practice Address - City:SMYRNA
Practice Address - State:DE
Practice Address - Zip Code:19977-1268
Practice Address - Country:US
Practice Address - Phone:302-653-1281
Practice Address - Fax:302-653-1283
Is Sole Proprietor?:No
Enumeration Date:2012-12-01
Last Update Date:2012-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000852207QA0000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine