Provider Demographics
NPI:1356436182
Name:MCCLELLAN, GLENN REX (PAC)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:REX
Last Name:MCCLELLAN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:125 SOUTH PARK DRIVE
Mailing Address - Street 2:STE B
Mailing Address - City:BROWNWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76801
Mailing Address - Country:US
Mailing Address - Phone:325-643-5445
Mailing Address - Fax:325-643-5447
Practice Address - Street 1:125 SOUTH PARK DRIVE
Practice Address - Street 2:STE B
Practice Address - City:BROWNWOOD
Practice Address - State:TX
Practice Address - Zip Code:76801
Practice Address - Country:US
Practice Address - Phone:325-643-5445
Practice Address - Fax:325-643-5447
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00707363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S17934Medicare UPIN
TX81N553Medicare ID - Type Unspecified