Provider Demographics
NPI:1548999147
Name:GLENN, AUTUMN WHITNEY (PA-C)
Entity type:Individual
Prefix:MS
First Name:AUTUMN
Middle Name:WHITNEY
Last Name:GLENN
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 1:559 VINCENT ST BLDG 725
Mailing Address - Street 2:
Mailing Address - City:PETERSON AFB
Mailing Address - State:CO
Mailing Address - Zip Code:80914-1541
Mailing Address - Country:US
Mailing Address - Phone:719-567-5536
Mailing Address - Fax:
Practice Address - Street 1:559 VINCENT ST BLDG 725
Practice Address - Street 2:
Practice Address - City:PETERSON AFB
Practice Address - State:CO
Practice Address - Zip Code:80914-1541
Practice Address - Country:US
Practice Address - Phone:719-567-5536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0007379363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant