Provider Demographics
NPI:1841342631
Name:GLICK, SHANTEL TANAE (PA-C)
Entity type:Individual
Prefix:
First Name:SHANTEL
Middle Name:TANAE
Last Name:GLICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21681 N 77TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-2132
Mailing Address - Country:US
Mailing Address - Phone:623-972-9200
Mailing Address - Fax:623-972-9209
Practice Address - Street 1:21681 N 77TH AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-2132
Practice Address - Country:US
Practice Address - Phone:623-972-9200
Practice Address - Fax:623-972-9209
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ3142363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ920513Medicaid
Z159355OtherMEDICARE PTAN