Provider Demographics
NPI:1366635666
Name:HUMPHRESS, GLENN B
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:B
Last Name:HUMPHRESS
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 1:8701 NEW TRAILS DR STE 150
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77381-4546
Mailing Address - Country:US
Mailing Address - Phone:214-803-6801
Mailing Address - Fax:281-367-1966
Practice Address - Street 1:8701 NEW TRAILS DR STE 150
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77381-4546
Practice Address - Country:US
Practice Address - Phone:281-367-1015
Practice Address - Fax:281-367-1966
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01469363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1366562225OtherFPW GROUP NPI
TXPA01469OtherPA