Provider Demographics
NPI:1568793297
Name:MCLOONE, ALICIA GAMBLE (PA-C)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:GAMBLE
Last Name:MCLOONE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:J
Other - Last Name:GAMBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:785 PRIMERA BLVD
Mailing Address - Street 2:SUITE# 1031
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-2124
Mailing Address - Country:US
Mailing Address - Phone:407-834-8111
Mailing Address - Fax:407-708-1985
Practice Address - Street 1:785 PRIMERA BLVD
Practice Address - Street 2:SUITE# 1031
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2124
Practice Address - Country:US
Practice Address - Phone:407-834-8111
Practice Address - Fax:407-708-1985
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105190207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002015600Medicaid