Provider Demographics
NPI:1588654628
Name:SOUTHAM, GLADE (NP)
Entity Type:Individual
Prefix:
First Name:GLADE
Middle Name:
Last Name:SOUTHAM
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BYU - IDAHO NURSING DEPARTMENT
Mailing Address - Street 2:117C CLARKE
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83460-0620
Mailing Address - Country:US
Mailing Address - Phone:208-496-1385
Mailing Address - Fax:208-496-5386
Practice Address - Street 1:BYU - IDAHO
Practice Address - Street 2:100 SHC
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83460-2010
Practice Address - Country:US
Practice Address - Phone:208-496-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP - 747A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily