Provider Demographics
NPI:1841168507
Name:OTHMAN GLENN, MEDINA KHADIJA (PA)
Entity type:Individual
Prefix:
First Name:MEDINA
Middle Name:KHADIJA
Last Name:OTHMAN GLENN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 22ND AVE E UNIT 104
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98112-5250
Mailing Address - Country:US
Mailing Address - Phone:971-899-1586
Mailing Address - Fax:
Practice Address - Street 1:119 22ND AVE E UNIT 104
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-5250
Practice Address - Country:US
Practice Address - Phone:971-899-1586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-24
Last Update Date:2025-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA70040194363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant