Provider Demographics
NPI:1750880589
Name:GLIDDEN, OLIVIA
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:GLIDDEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W 57TH ST STE 307
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-3211
Mailing Address - Country:US
Mailing Address - Phone:917-410-6905
Mailing Address - Fax:646-878-6095
Practice Address - Street 1:200 W 57TH ST STE 307
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-3211
Practice Address - Country:US
Practice Address - Phone:917-410-6905
Practice Address - Fax:646-878-6095
Is Sole Proprietor?:No
Enumeration Date:2018-02-07
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008533363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant