Provider Demographics
NPI:1710291612
Name:GLASS, ANTHONY TODD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:TODD
Last Name:GLASS
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:890 W FARIS RD
Practice Address - Street 2:SUITE 550
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4253
Practice Address - Country:US
Practice Address - Phone:864-455-6800
Practice Address - Fax:864-455-6825
Is Sole Proprietor?:No
Enumeration Date:2010-08-03
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1720363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1287PAMedicaid
SCAA78627951Medicare PIN
SCAA78625019Medicare PIN