Provider Demographics
NPI:1205913720
Name:DUBOIS, GLEN LOUIS (PA-C)
Entity type:Individual
Prefix:MR
First Name:GLEN
Middle Name:LOUIS
Last Name:DUBOIS
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 1:2502 MORGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78405-1807
Mailing Address - Country:US
Mailing Address - Phone:361-888-6782
Mailing Address - Fax:361-882-3076
Practice Address - Street 1:2502 MORGAN AVE
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78405-1807
Practice Address - Country:US
Practice Address - Phone:361-888-6782
Practice Address - Fax:361-882-3076
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA004465363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT00069083OtherBLUE SHIELD
VT00069083OtherBLUE SHIELD
VTAP2580Medicare ID - Type Unspecified