Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 213E00000X | Podiatrist | E1-0000169 | DE |
N | 222Z00000X | Podiatrist | E1-0000169 | DE |
Y | 213E00000X | Podiatrist | SC005575L | PA |
Y | 222Z00000X | Podiatrist | SC005575L | PA |
NPI | 1063400877 |
---|---|
Provider Name | Dr. Troels Glysing-Jensen |
First Address | Wayne, PA 19087-3537 |
Second Address | Wayne, PA 19087-3537 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/10/2005 |
Last Update Date | 12/02/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1000035515 | (05) | DE |
1011912040001 | (05) | PA |
E1-0000169 | LICENSE (01) | DE |
SC005575L | LICENSE (01) | PA |
U98631 | (02) | PA |