Provider Demographics
NPI:1336270081
Name:GLICK, BRIAN H (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:H
Last Name:GLICK
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 1:96 HUBBS RD
Mailing Address - Street 2:
Mailing Address - City:BALLSTON LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12019-2203
Mailing Address - Country:US
Mailing Address - Phone:518-406-5374
Mailing Address - Fax:
Practice Address - Street 1:1205 TROY SCHENECTADY RD STE 101
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-1074
Practice Address - Country:US
Practice Address - Phone:518-348-3176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005627-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant