Provider Demographics
NPI:1316360985
Name:GLASCOCK, PATRICK (RT (R))
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:GLASCOCK
Suffix:
Gender:M
Credentials:RT (R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 W CANFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-0413
Mailing Address - Country:US
Mailing Address - Phone:208-640-1693
Mailing Address - Fax:
Practice Address - Street 1:5260 W HAYDEN AVE
Practice Address - Street 2:
Practice Address - City:RATHDRUM
Practice Address - State:ID
Practice Address - Zip Code:83858-9467
Practice Address - Country:US
Practice Address - Phone:208-660-5943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-31
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR9144692471C3402X
WART 604068322471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography