Provider Demographics
NPI:1174582597
Name:UPDYKE, GLENDA M (MS PA-C)
Entity type:Individual
Prefix:
First Name:GLENDA
Middle Name:M
Last Name:UPDYKE
Suffix:
Gender:F
Credentials:MS PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PRESTIGE PL STE 550
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6115
Mailing Address - Country:US
Mailing Address - Phone:937-762-1310
Mailing Address - Fax:937-522-8068
Practice Address - Street 1:600 W MAIN ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-3384
Practice Address - Country:US
Practice Address - Phone:937-395-6665
Practice Address - Fax:937-395-6668
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001269363AS0400X
OH50.001269363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0085241Medicaid
OHPA14826Medicare PIN
OHPA14827Medicare PIN
OHH024500Medicare PIN
OH0085241Medicaid