Provider Demographics
NPI:1205011475
Name:GIFFORD, GLENN ERIC (PA C)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:ERIC
Last Name:GIFFORD
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 FREEPORT RD
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15238-3100
Mailing Address - Country:US
Mailing Address - Phone:412-325-5000
Mailing Address - Fax:412-696-0381
Practice Address - Street 1:970 FREEPORT RD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15238-3100
Practice Address - Country:US
Practice Address - Phone:412-325-5000
Practice Address - Fax:412-696-0381
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053012363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
13654471OtherCAQH