Provider Demographics
NPI:1144955956
Name:GLAZE, JUSTIN MATTHEW (MSN, APRN, FNP-C)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:MATTHEW
Last Name:GLAZE
Suffix:
Gender:M
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1900
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30722-1900
Mailing Address - Country:US
Mailing Address - Phone:706-272-6000
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 1900
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30722-1900
Practice Address - Country:US
Practice Address - Phone:706-272-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-18
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN268132363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily