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:
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Provider Licenses
StateLicense IDTaxonomies
GA002538363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11529519OtherCAQH
GA100002134BMedicaid
GA100002134BMedicaid
GA100002134BMedicaid