Provider Demographics
NPI:1952818684
Name:MCCLEASE, MACON O'BRIAN SR (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MACON
Middle Name:O'BRIAN
Last Name:MCCLEASE
Suffix:SR
Gender:M
Credentials:CRNA
Other - Prefix:
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Mailing Address - Street 1:134 BUSINESS PARK AVE
Mailing Address - Street 2:
Mailing Address - City:VA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-2626
Mailing Address - Country:US
Mailing Address - Phone:757-473-0055
Mailing Address - Fax:757-473-0075
Practice Address - Street 1:600 GRESHAM DR
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1904
Practice Address - Country:US
Practice Address - Phone:757-473-0055
Practice Address - Fax:757-473-0075
Is Sole Proprietor?:No
Enumeration Date:2018-01-03
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0024367500000X
VA0024175722367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered