Provider Demographics
NPI:1336714633
Name:GLISSON, CASEY
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:GLISSON
Suffix:
Gender:M
Credentials:
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 325
Mailing Address - Street 2:
Mailing Address - City:MAYNARD
Mailing Address - State:AR
Mailing Address - Zip Code:72444-0325
Mailing Address - Country:US
Mailing Address - Phone:810-870-3556
Mailing Address - Fax:
Practice Address - Street 1:13502 HIGHWAY 115 N
Practice Address - Street 2:
Practice Address - City:MAYNARD
Practice Address - State:AR
Practice Address - Zip Code:72444-0325
Practice Address - Country:US
Practice Address - Phone:810-870-3556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1099358367500000X
ARR103778390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program