Provider Demographics
NPI:1366635666
Name:HUMPHRESS, GLENN B
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:B
Last Name:HUMPHRESS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2219 SAWDUST RD STE 1505
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380-2581
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2219 SAWDUST RD STE 1505
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-2581
Practice Address - Country:US
Practice Address - Phone:346-291-3832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01469363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1366562225OtherFPW GROUP NPI
TXPA01469OtherPA