Provider Demographics
NPI:1114476140
Name:MCLEAN, LISA RUTH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:RUTH
Last Name:MCLEAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:RUTH
Other - Last Name:COCCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:17500 FEDERAL DR STE 750
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-3656
Mailing Address - Country:US
Mailing Address - Phone:313-982-1370
Mailing Address - Fax:313-982-1376
Practice Address - Street 1:17500 FEDERAL DR STE 750
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-3656
Practice Address - Country:US
Practice Address - Phone:313-982-1370
Practice Address - Fax:313-982-1376
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI56010089382083X0100X, 363AM0700X
CAPA53731363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine