Provider Demographics
NPI:1639188832
Name:MACLEAN, GLENN (PAC)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:MACLEAN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38135 MARKET SQUARE
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542
Mailing Address - Country:US
Mailing Address - Phone:813-780-1255
Mailing Address - Fax:
Practice Address - Street 1:2100 VIA BELLA BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34639-5403
Practice Address - Country:US
Practice Address - Phone:813-948-1498
Practice Address - Fax:813-909-8113
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA37329363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00909173OtherRR MEDICARE
P37329Medicare UPIN
FLE5978UMedicare PIN