Provider Demographics
NPI:1013088194
Name:HORNE, GLEN ROLAND (CRNA)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:ROLAND
Last Name:HORNE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CALHOUN AVE
Mailing Address - Street 2:UNIT 606
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-5509
Mailing Address - Country:US
Mailing Address - Phone:404-310-6048
Mailing Address - Fax:404-255-1831
Practice Address - Street 1:5 CALHOUN AVE
Practice Address - Street 2:UNIT 606
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-5509
Practice Address - Country:US
Practice Address - Phone:404-310-6048
Practice Address - Fax:404-255-1831
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9397267367500000X
NC110691367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA156961100OtherU.S. DEPT OF LABOR
GA52159539-001OtherBLUE CROSS BLUE SHIELD
GA9975585OtherUNIVERSAL HEALTHCARE
GA430010318OtherRAIL ROAD MEDICARE
GA430010318OtherTRI-CARE
GA000521435BMedicaid
GA20-02624OtherUNITED HEALTHCARE
GA9975585OtherUNIVERSAL HEALTHCARE
GA52159539-001OtherBLUE CROSS BLUE SHIELD