Provider Demographics
NPI:1700868239
Name:GLAVIN, KAREN (PA-C)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:GLAVIN
Suffix:
Gender:F
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 1:225000 HUMMINGBIRD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-2950
Mailing Address - Country:US
Mailing Address - Phone:715-359-6442
Mailing Address - Fax:715-393-0390
Practice Address - Street 1:1767 PARK AVE STE 100
Practice Address - Street 2:
Practice Address - City:PLOVER
Practice Address - State:WI
Practice Address - Zip Code:54467-4301
Practice Address - Country:US
Practice Address - Phone:715-344-1260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA4380363AS0400X
FLPA9101667363AS0400X
WI4517-23363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291073000Medicaid
FLP40738001Medicare UPIN
FL291073000Medicaid