Provider Demographics
NPI:1497220289
Name:MCGLOTHIN, ANTWAIN
Entity type:Individual
Prefix:
First Name:ANTWAIN
Middle Name:
Last Name:MCGLOTHIN
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 1:4747 RESEARCH FOREST DR STE 165
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77381-4908
Mailing Address - Country:US
Mailing Address - Phone:512-745-0000
Mailing Address - Fax:
Practice Address - Street 1:3801 N LAMAR BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-4080
Practice Address - Country:US
Practice Address - Phone:512-407-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT390200000X
TXPA14120363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program