Provider Demographics
NPI:1043623663
Name:GLASS, NATHAN T (PA-C)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:T
Last Name:GLASS
Suffix:
Gender:M
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 1:100 RIDGEVIEW DR # 100
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:15478-1650
Mailing Address - Country:US
Mailing Address - Phone:724-569-8100
Mailing Address - Fax:
Practice Address - Street 1:100 RIDGEVIEW DR STE 100
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:PA
Practice Address - Zip Code:15478-1650
Practice Address - Country:US
Practice Address - Phone:724-569-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA0624987363AM0700X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0N51OtherBCBS
FL014300000Medicaid
FLP01483887OtherRR MCR
FLY0N51OtherBCBS
FLHW810XMedicare PIN
FLHW810YMedicare PIN