Provider Demographics
NPI:1760478655
Name:GLASS, GINA E (PA)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:E
Last Name:GLASS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:GEORGINA
Other - Middle Name:ELSRE
Other - Last Name:GLASS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-353-8868
Mailing Address - Fax:319-384-9697
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-353-8868
Practice Address - Fax:319-384-9697
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000624363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA43233OtherWELLMARK BCBS
IA43233OtherWELLMARK BCBS
P46595Medicare UPIN