Provider Demographics
NPI:1801888763
Name:MCCLELLAN, LISA (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:MCCLELLAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31001-0698
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-0698
Mailing Address - Country:US
Mailing Address - Phone:602-263-1200
Mailing Address - Fax:602-200-5383
Practice Address - Street 1:500 W THOMAS RD
Practice Address - Street 2:STE 870
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4218
Practice Address - Country:US
Practice Address - Phone:877-809-0509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25023207Q00000X, 207Q00000X
DCMD040638207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZG68771Medicare UPIN