Provider Demographics
NPI:1104011659
Name:GLASSOCK, ANGELA L (PT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:L
Last Name:GLASSOCK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-3606
Mailing Address - Country:US
Mailing Address - Phone:307-672-2092
Mailing Address - Fax:307-673-1969
Practice Address - Street 1:50 W 3RD ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-3606
Practice Address - Country:US
Practice Address - Phone:307-672-2092
Practice Address - Fax:307-673-1969
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT673225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW21547Medicare PIN