Provider Demographics
NPI:1336209105
Name:MCCLAIN, GLEN (CRNA)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:MCCLAIN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:GLEN
Other - Middle Name:
Other - Last Name:MCCLAIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:400 HARBORSIDE DR
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77555-0001
Mailing Address - Country:US
Mailing Address - Phone:409-772-0848
Mailing Address - Fax:409-772-0885
Practice Address - Street 1:301 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-1022
Practice Address - Country:US
Practice Address - Phone:409-772-0848
Practice Address - Fax:409-772-0885
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX225578367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXR92690Medicare UPIN
TX83918HMedicare ID - Type Unspecified