Provider Demographics
NPI:1770570822
Name:STANLEY, GLENN M (PA-C)
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:M
Last Name:STANLEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:7169 GOLDSBORO RD
Mailing Address - Street 2:
Mailing Address - City:WADE
Mailing Address - State:NC
Mailing Address - Zip Code:28395-8959
Mailing Address - Country:US
Mailing Address - Phone:910-717-1714
Mailing Address - Fax:
Practice Address - Street 1:420 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3430
Practice Address - Country:US
Practice Address - Phone:910-484-1210
Practice Address - Fax:910-484-1347
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102083363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2752748HMedicare PIN
P01893Medicare UPIN