Provider Demographics
NPI:1194425298
Name:MCCLENDON, LISSA NGUYEN (PA)
Entity type:Individual
Prefix:
First Name:LISSA
Middle Name:NGUYEN
Last Name:MCCLENDON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:800 W MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4611
Mailing Address - Country:US
Mailing Address - Phone:817-759-7000
Mailing Address - Fax:817-759-7027
Practice Address - Street 1:515 W MAYFIELD RD STE 102
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76014-2084
Practice Address - Country:US
Practice Address - Phone:817-759-7000
Practice Address - Fax:817-759-7027
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-07
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA16783363AS0400X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA16783OtherSTATE LICENSE