Provider Demographics
NPI:1538581384
Name:HINES, GLENROY JR (PA-C)
Entity type:Individual
Prefix:
First Name:GLENROY
Middle Name:
Last Name:HINES
Suffix:JR
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 1:500 E ROBINSON ST
Mailing Address - Street 2:STE 1300
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-6697
Mailing Address - Country:US
Mailing Address - Phone:405-360-9966
Mailing Address - Fax:405-360-9905
Practice Address - Street 1:500 E ROBINSON ST
Practice Address - Street 2:STE 1300
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-6697
Practice Address - Country:US
Practice Address - Phone:405-360-9966
Practice Address - Fax:405-360-9905
Is Sole Proprietor?:No
Enumeration Date:2014-01-14
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2341208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2341OtherOKLAHOMA STATE MEDICAL LICENSE