Provider Demographics
NPI:1114367737
Name:MCLAREN, SUSAN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:MCLAREN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:GALLUCCI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:45515 MUIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-1098
Mailing Address - Country:US
Mailing Address - Phone:734-748-9399
Mailing Address - Fax:
Practice Address - Street 1:10909 HANNAN RD
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-1383
Practice Address - Country:US
Practice Address - Phone:734-941-1142
Practice Address - Fax:734-955-6973
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001901363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant