Provider Demographics
NPI:1962493932
Name:MCCLANAHAN, WILLIAM SHANE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:SHANE
Last Name:MCCLANAHAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 KINGSLEY AVE STE 14A
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4541
Mailing Address - Country:US
Mailing Address - Phone:904-213-3555
Mailing Address - Fax:904-272-1222
Practice Address - Street 1:1409 KINGSLEY AVE STE 14A
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4541
Practice Address - Country:US
Practice Address - Phone:904-213-3555
Practice Address - Fax:904-272-1222
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2114363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291267800Medicaid
E5420Medicare PIN
FL291267800Medicaid