Provider Demographics
NPI:1295195360
Name:GLAZER, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:GLAZER
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 1:8114 SANDPIPER CIR
Mailing Address - Street 2:SUITE 206
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4934
Mailing Address - Country:US
Mailing Address - Phone:410-933-4923
Mailing Address - Fax:410-933-8659
Practice Address - Street 1:8114 SANDPIPER CIR
Practice Address - Street 2:SUITE 206
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21236-4934
Practice Address - Country:US
Practice Address - Phone:410-933-4923
Practice Address - Fax:410-933-8659
Is Sole Proprietor?:No
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR204261363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care