Provider Demographics
NPI:1952323354
Name:GLYNN, LEONARD C (PA-C)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:C
Last Name:GLYNN
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 1:5612 WHITESVILLE RD STE B
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-9031
Mailing Address - Country:US
Mailing Address - Phone:706-322-2223
Mailing Address - Fax:706-324-5233
Practice Address - Street 1:5612 WHITESVILLE RD STE B
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904
Practice Address - Country:US
Practice Address - Phone:706-322-2223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002654363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100001537BMedicaid
GA97WCFWCMedicare ID - Type UnspecifiedMEDICARE ID NUMBER
GAS86352Medicare UPIN