Provider Demographics
NPI:1578792172
Name:MCLEAN, ELIZABETH FATU (PAC)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:FATU
Last Name:MCLEAN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:FATU
Other - Last Name:GABRIELLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:52 W SHIRLEY AVE
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20186-3008
Mailing Address - Country:US
Mailing Address - Phone:540-347-9220
Mailing Address - Fax:540-347-0492
Practice Address - Street 1:52 W SHIRLEY AVE
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186-3008
Practice Address - Country:US
Practice Address - Phone:540-347-9220
Practice Address - Fax:540-347-0492
Is Sole Proprietor?:No
Enumeration Date:2009-07-06
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003032363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical