Provider Demographics
NPI:1205045093
Name:GLAUDE, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GLAUDE
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 1:2500 STARLING ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4265
Mailing Address - Country:US
Mailing Address - Phone:912-265-5125
Mailing Address - Fax:
Practice Address - Street 1:2500 STARLING ST
Practice Address - Street 2:SUITE 201
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4265
Practice Address - Country:US
Practice Address - Phone:912-265-5125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002782363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003132355AMedicaid
GA202I971787Medicare PIN