Provider Demographics
NPI:1699199380
Name:GLASS, GARY
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:GLASS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-2858
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:720 W CHEYENNE AVE
Practice Address - Street 2:2909 WHITE PEAKS
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-7807
Practice Address - Country:US
Practice Address - Phone:702-834-4703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-14
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker