Provider Demographics
NPI:1356314025
Name:GLICK, NITZA L (PA-C)
Entity Type:Individual
Prefix:
First Name:NITZA
Middle Name:L
Last Name:GLICK
Suffix:
Gender:F
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 1:107 E OAK AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1818
Mailing Address - Country:US
Mailing Address - Phone:928-773-2560
Mailing Address - Fax:928-913-8835
Practice Address - Street 1:107 E OAK AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1818
Practice Address - Country:US
Practice Address - Phone:928-773-2560
Practice Address - Fax:928-913-8835
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1974363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
74095Medicare ID - Type Unspecified
S35198Medicare UPIN