Provider Demographics
NPI:1538306345
Name:EWING, GLEN MARTIN (GRNA)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:MARTIN
Last Name:EWING
Suffix:
Gender:M
Credentials:GRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07080-3601
Mailing Address - Country:US
Mailing Address - Phone:908-963-6192
Mailing Address - Fax:
Practice Address - Street 1:150 BERGEN ST
Practice Address - Street 2:RM#E-245
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2496
Practice Address - Country:US
Practice Address - Phone:973-972-7867
Practice Address - Fax:973-972-2357
Is Sole Proprietor?:No
Enumeration Date:2009-01-15
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NO11090200367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered