Provider Demographics
NPI:1023090487
Name:PHILLIPS, GLENN (PA)
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:
Last Name:PHILLIPS
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 1:17360 BROOKHURST ST
Mailing Address - Street 2:ATTN: CREDENTIALING DEPARTMENT
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-3720
Mailing Address - Country:US
Mailing Address - Phone:657-241-3592
Mailing Address - Fax:
Practice Address - Street 1:23512 MADERO
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-2743
Practice Address - Country:US
Practice Address - Phone:949-583-1600
Practice Address - Fax:949-454-8067
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 10513363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA10513Medicaid
CAET485ZMedicare PIN
CAR40110Medicare UPIN
CAWPA10513EMedicare PIN