Provider Demographics
NPI:1649218546
Name:GLAZEWSKI, ROBERT WALTER (PA C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:WALTER
Last Name:GLAZEWSKI
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 84026
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-8426
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:1909 214TH ST SE STE 300
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98021-4418
Practice Address - Country:US
Practice Address - Phone:425-412-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003728363A00000X, 207Q00000X
WA1039568363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8413GLOtherBSWA
WA0227451OtherLIWA
WA8318719Medicaid
WA7910GLOtherLIWA
WA0194427OtherLIWA
WA7073596Medicaid
WA0227451OtherLIWA
WA8413GLOtherBSWA
WA8318719Medicaid
WAG8868543Medicare PIN
WAP00366411Medicare PIN
WAG8866811Medicare PIN