Provider Demographics
NPI:1740891829
Name:GLAZE, DANIEL (ARNP)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:GLAZE
Suffix:
Gender:M
Credentials:ARNP
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 190
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:WA
Mailing Address - Zip Code:99159-0190
Mailing Address - Country:US
Mailing Address - Phone:509-982-2614
Mailing Address - Fax:
Practice Address - Street 1:510 E AMENDE DR
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:WA
Practice Address - Zip Code:99159-7003
Practice Address - Country:US
Practice Address - Phone:509-982-2614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61088074363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily