Provider Demographics
NPI:1972692184
Name:MARTIN, GLENN WILLIAM (PA-C)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:WILLIAM
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:4971 COUNTY ROAD 250
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-8620
Mailing Address - Country:US
Mailing Address - Phone:970-247-2982
Mailing Address - Fax:970-247-2982
Practice Address - Street 1:2700 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-4559
Practice Address - Country:US
Practice Address - Phone:505-325-1100
Practice Address - Fax:505-325-5044
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM77 PA 005 NM363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant