Provider Demographics
NPI:1174916365
Name:GLASS, ALEXANDRIA BASS (DO)
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:BASS
Last Name:GLASS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 E JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28328-2806
Mailing Address - Country:US
Mailing Address - Phone:910-490-1240
Mailing Address - Fax:910-490-1260
Practice Address - Street 1:412 E JOHNSON ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-2806
Practice Address - Country:US
Practice Address - Phone:910-490-1240
Practice Address - Fax:910-490-1260
Is Sole Proprietor?:No
Enumeration Date:2015-03-11
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA78561207N00000X
GA078561207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology