Provider Demographics
NPI:1780045203
Name:GLOVER, MEGHAN TALLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:TALLEY
Last Name:GLOVER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MEGHAN
Other - Middle Name:CHRISTINE
Other - Last Name:TALLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3635 VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2539
Mailing Address - Country:US
Mailing Address - Phone:314-577-8715
Mailing Address - Fax:314-577-8720
Practice Address - Street 1:3635 VISTA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2539
Practice Address - Country:US
Practice Address - Phone:314-577-8715
Practice Address - Fax:314-577-8720
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016006297363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical