Provider Demographics
NPI:1952327447
Name:HISS, GLEN A (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:A
Last Name:HISS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W 8TH AVE STE 6020
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2319
Mailing Address - Country:US
Mailing Address - Phone:509-455-5050
Mailing Address - Fax:509-789-6204
Practice Address - Street 1:105 W 8TH AVE STE 6020
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2319
Practice Address - Country:US
Practice Address - Phone:509-455-5050
Practice Address - Fax:509-789-6204
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00023748207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1015445Medicaid
WAA07468Medicare UPIN
WA1015445Medicaid