Provider Demographics
NPI:1366414724
Name:MCKEON, GLENN R (PA-C)
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:R
Last Name:MCKEON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:PO BOX 1777
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32158-1777
Mailing Address - Country:US
Mailing Address - Phone:352-259-7994
Mailing Address - Fax:352-259-7992
Practice Address - Street 1:607 HIGHWAY 466
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-6338
Practice Address - Country:US
Practice Address - Phone:352-259-7994
Practice Address - Fax:352-259-7992
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA1759363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS59892Medicare UPIN