Provider Demographics
NPI:1659412575
Name:SOLDAN, GLENN (AA)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:SOLDAN
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 SCOTT NIXON MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-2464
Mailing Address - Country:US
Mailing Address - Phone:800-394-4445
Mailing Address - Fax:
Practice Address - Street 1:6605 ABERCORN ST
Practice Address - Street 2:ST 108
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-5815
Practice Address - Country:US
Practice Address - Phone:912-354-5357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004361367H00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA32BBBJNMedicare PIN