Provider Demographics
NPI:1295856490
Name:MCCLELLAN, NATHANIEL H (MT)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:H
Last Name:MCCLELLAN
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 TEMPLE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-4011
Mailing Address - Country:US
Mailing Address - Phone:207-773-8393
Mailing Address - Fax:
Practice Address - Street 1:19 TEMPLE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4011
Practice Address - Country:US
Practice Address - Phone:207-773-8393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT3072174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME099082OtherANTHEM