Provider Demographics
NPI:1699032607
Name:CASCOLAN, GLYNN CONCEPCION (RN)
Entity Type:Individual
Prefix:
First Name:GLYNN
Middle Name:CONCEPCION
Last Name:CASCOLAN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1485 GRAEBER ST
Mailing Address - Street 2:BLDG 2300
Mailing Address - City:MARCH AIR RESERVE BASE
Mailing Address - State:CA
Mailing Address - Zip Code:92518-1728
Mailing Address - Country:US
Mailing Address - Phone:951-655-2773
Mailing Address - Fax:
Practice Address - Street 1:1485 GRAEBER ST
Practice Address - Street 2:BLDG 2300
Practice Address - City:MARCH AIR RESERVE BASE
Practice Address - State:CA
Practice Address - Zip Code:92518-1728
Practice Address - Country:US
Practice Address - Phone:951-655-2773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-15
Last Update Date:2012-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA481112163W00000X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health