Provider Demographics
NPI:1801481205
Name:GLOVER, BROCK A
Entity type:Individual
Prefix:
First Name:BROCK
Middle Name:A
Last Name:GLOVER
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 1:3501 S BLAIR STONE RD APT 218
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-6988
Mailing Address - Country:US
Mailing Address - Phone:850-545-9443
Mailing Address - Fax:
Practice Address - Street 1:1300 MICCOSUKEE RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5054
Practice Address - Country:US
Practice Address - Phone:850-431-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11008476363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily