Provider Demographics
NPI:1255767513
Name:GLAZE, NICHOLAS RYAN (NP)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:RYAN
Last Name:GLAZE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9101
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-9494
Mailing Address - Country:US
Mailing Address - Phone:972-906-8124
Mailing Address - Fax:972-745-4376
Practice Address - Street 1:345 N HIGHWAY 67
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-2134
Practice Address - Country:US
Practice Address - Phone:972-956-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-18
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX784995363L00000X
TXAP124430363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP124430OtherTEXAS BNE
TX784995OtherTEXAS BNE