Individual
GLENN JOSEPH LYSACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
5151 N 9TH AVE, PENSACOLA, FL 32504-8721
(850) 416-7000
Mailing address
PO BOX 2699, PENSACOLA, FL 32513-2699
(850) 416-7000
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA3242
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
292120100
—
FL
Enumeration date
06/04/2006
Last updated
01/16/2018
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