Provider Demographics
NPI:1578817466
Name:GLICK, KELLY LEAH (PAC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LEAH
Last Name:GLICK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 FAIRWAY ST
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-2639
Mailing Address - Country:US
Mailing Address - Phone:701-456-4200
Mailing Address - Fax:701-456-4545
Practice Address - Street 1:2500 FAIRWAY ST
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-2639
Practice Address - Country:US
Practice Address - Phone:701-456-4200
Practice Address - Fax:701-456-4545
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0507363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1452926Medicaid
ND71219Medicaid
ND71219Medicaid
NDN718461Medicare PIN