Provider Demographics
NPI:1639446271
Name:MCCLELLAND, MENDY COOPER (PA)
Entity Type:Individual
Prefix:
First Name:MENDY
Middle Name:COOPER
Last Name:MCCLELLAND
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MENDY
Other - Middle Name:NICOLE
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:47 HIGHWAY 64 W
Mailing Address - Street 2:
Mailing Address - City:BEEBE
Mailing Address - State:AR
Mailing Address - Zip Code:72012-9500
Mailing Address - Country:US
Mailing Address - Phone:501-882-3388
Mailing Address - Fax:501-882-3300
Practice Address - Street 1:47 HIGHWAY 64 W
Practice Address - Street 2:
Practice Address - City:BEEBE
Practice Address - State:AR
Practice Address - Zip Code:72012-9500
Practice Address - Country:US
Practice Address - Phone:501-882-3388
Practice Address - Fax:501-882-3300
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE 0000363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR57297Medicare PIN