Provider Demographics
NPI:1477726842
Name:MCCLURE, GWEN ANN (LPTA)
Entity Type:Individual
Prefix:MRS
First Name:GWEN
Middle Name:ANN
Last Name:MCCLURE
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:481 OAKLAWN AVE
Mailing Address - Street 2:481 OAKLAWN AVENUE
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-4929
Mailing Address - Country:US
Mailing Address - Phone:920-433-0533
Mailing Address - Fax:
Practice Address - Street 1:481 OAKLAWN AVE
Practice Address - Street 2:481 OAKLAWN AVENUE
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-4929
Practice Address - Country:US
Practice Address - Phone:920-433-0533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1037-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40211400Medicaid