Provider Demographics
NPI:1467107656
Name:GLASS, SIDNEY LYLE (FNP-C)
Entity Type:Individual
Prefix:
First Name:SIDNEY
Middle Name:LYLE
Last Name:GLASS
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 BROOK RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-3705
Mailing Address - Country:US
Mailing Address - Phone:804-698-9451
Mailing Address - Fax:
Practice Address - Street 1:1000 E MARSHALL ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-1900
Practice Address - Country:US
Practice Address - Phone:804-827-3306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024182217363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily