Provider Demographics
NPI:1013656867
Name:REGAN, GLORIOSE BUTOYI I
Entity Type:Individual
Prefix:MISS
First Name:GLORIOSE
Middle Name:BUTOYI
Last Name:REGAN
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3305 SE 22ND ST APT 30
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50320-1962
Mailing Address - Country:US
Mailing Address - Phone:515-718-2723
Mailing Address - Fax:
Practice Address - Street 1:3305 SE 22ND ST APT 30
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50320-1962
Practice Address - Country:US
Practice Address - Phone:515-718-2723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA357AR5065343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)