Provider Demographics
NPI:1629059852
Name:FERGUSON, GLORI ELIZEBETH (NP)
Entity Type:Individual
Prefix:
First Name:GLORI
Middle Name:ELIZEBETH
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1427 IDLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-3427
Mailing Address - Country:US
Mailing Address - Phone:432-272-3215
Mailing Address - Fax:
Practice Address - Street 1:1427 IDLEWOOD LN
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-3427
Practice Address - Country:US
Practice Address - Phone:432-272-3215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX632473363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00631XMedicare ID - Type UnspecifiedGROUP NUMBER