Provider Demographics
NPI: | 1497973325 |
---|---|
Name: | MCGLYNN, PAUL V JR (PA) |
Entity Type: | Individual |
Prefix: | |
First Name: | PAUL |
Middle Name: | V |
Last Name: | MCGLYNN |
Suffix: | JR |
Gender: | M |
Credentials: | PA |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 49TH MEDICAL GROUP/SGOPF |
Mailing Address - Street 2: | 280 FIRST STREET, BLDG 23 |
Mailing Address - City: | HOLLOMAN AFB |
Mailing Address - State: | NM |
Mailing Address - Zip Code: | 88330-8273 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 575-572-7091 |
Mailing Address - Fax: | 575-572-2259 |
Practice Address - Street 1: | 49TH MEDICAL GROUP/SGOPF |
Practice Address - Street 2: | 280 FIRST STREET, BLDG 23 |
Practice Address - City: | HOLLOMAN AFB |
Practice Address - State: | NM |
Practice Address - Zip Code: | 88330-8273 |
Practice Address - Country: | US |
Practice Address - Phone: | 575-572-7091 |
Practice Address - Fax: | 575-572-2259 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2007-04-24 |
Last Update Date: | 2018-04-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
GA | 002538 | 363A00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
GA | 11529519 | Other | CAQH |
GA | 100002134B | Medicaid | |
GA | 100002134B | Medicaid | |
GA | 100002134B | Medicaid |