Provider Demographics
NPI:1407033459
Name:GLANZ, ROBERT J (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:J
Last Name:GLANZ
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 1:110 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-2507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 W 6TH ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2507
Practice Address - Country:US
Practice Address - Phone:315-349-5511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-22
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012420207P00000X
MA1400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1407033459Medicaid
NY1407033459Medicaid
P65445Medicare UPIN