Provider Demographics
NPI:1295921112
Name:CARLTON, GLENN DEAN (CRNA)
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:DEAN
Last Name:CARLTON
Suffix:
Gender:M
Credentials:CRNA
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 88
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63902-0088
Mailing Address - Country:US
Mailing Address - Phone:573-727-2724
Mailing Address - Fax:573-727-2788
Practice Address - Street 1:621 W PINE ST
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-5042
Practice Address - Country:US
Practice Address - Phone:573-686-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005036504367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered