Provider Demographics
NPI:1366019085
Name:RICCIO, GLENN MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:MICHAEL
Last Name:RICCIO
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 1:365 TYLER DR
Mailing Address - Street 2:
Mailing Address - City:CLEAR BROOK
Mailing Address - State:VA
Mailing Address - Zip Code:22624-1662
Mailing Address - Country:US
Mailing Address - Phone:434-326-2164
Mailing Address - Fax:
Practice Address - Street 1:365 TYLER DR
Practice Address - Street 2:
Practice Address - City:CLEAR BROOK
Practice Address - State:VA
Practice Address - Zip Code:22624-1662
Practice Address - Country:US
Practice Address - Phone:434-326-2164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110007920363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant