Provider Demographics
NPI:1235102211
Name:COMBS, GLEN EDWARD (PA)
Entity type:Individual
Prefix:MR
First Name:GLEN
Middle Name:EDWARD
Last Name:COMBS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 BURKEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-3945
Mailing Address - Country:US
Mailing Address - Phone:336-970-3800
Mailing Address - Fax:
Practice Address - Street 1:2255 LEWISVILLE CLEMMONS RD
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-7463
Practice Address - Country:US
Practice Address - Phone:336-766-0505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101309363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009241E25Medicaid
VA-010OtherCHAMPUS/TRICARE
NC101309OtherMEDICAL BOARD LICENSE
NCMC1309384OtherDEA
NC101309OtherMEDICAL BOARD LICENSE
VA568416Medicare UPIN