Provider Demographics
NPI:1932297876
Name:GLASS, KATHLEEN (MS, CRNA)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:
Last Name:GLASS
Suffix:
Gender:F
Credentials:MS, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 BLAZIER RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:NJ
Mailing Address - Zip Code:07059-6929
Mailing Address - Country:US
Mailing Address - Phone:732-560-3890
Mailing Address - Fax:
Practice Address - Street 1:187 MILLBURN AVE
Practice Address - Street 2:
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041-1847
Practice Address - Country:US
Practice Address - Phone:973-467-1466
Practice Address - Fax:973-467-1422
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR12327000367500000X
FLAPRN9479375367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ113040A01Medicare PIN
NJ113040Medicare PIN