Provider Demographics
NPI:1265401756
Name:GLICK, GREG (PAC)
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:GLICK
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:GREGORY
Other - Middle Name:JOSEPH
Other - Last Name:GLICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PAC
Mailing Address - Street 1:2600 CAMPUS DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-3357
Mailing Address - Country:US
Mailing Address - Phone:303-673-1900
Mailing Address - Fax:303-673-1915
Practice Address - Street 1:2600 CAMPUS DR
Practice Address - Street 2:SUITE A
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-3357
Practice Address - Country:US
Practice Address - Phone:303-673-1900
Practice Address - Fax:303-673-1915
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2005-0016363A00000X
COPA-2290363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO76459551Medicaid
CO76459551Medicaid