Provider Demographics
NPI:1649928078
Name:GLIJIN, VEACESLAV
Entity type:Individual
Prefix:
First Name:VEACESLAV
Middle Name:
Last Name:GLIJIN
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 1:1624 S I ST STE 305
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5093
Mailing Address - Country:US
Mailing Address - Phone:253-428-8700
Mailing Address - Fax:
Practice Address - Street 1:1624 S I ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-5016
Practice Address - Country:US
Practice Address - Phone:253-428-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-15
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61362994363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant