Provider Demographics
NPI:1164287686
Name:GLASSON, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GLASSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7719 BRIDLEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:IL
Mailing Address - Zip Code:61011-9011
Mailing Address - Country:US
Mailing Address - Phone:815-222-9242
Mailing Address - Fax:
Practice Address - Street 1:7719 BRIDLEWOOD RD
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:IL
Practice Address - Zip Code:61011-9011
Practice Address - Country:US
Practice Address - Phone:815-222-9242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041249330163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant