Provider Demographics
NPI:1588050595
Name:MCCLELLAN, RYAN (MD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MCCLELLAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4915 E BASELINE RD STE 119
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2969
Mailing Address - Country:US
Mailing Address - Phone:480-832-0480
Mailing Address - Fax:480-832-0490
Practice Address - Street 1:4915 E BASELINE RD STE 119
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2969
Practice Address - Country:US
Practice Address - Phone:480-832-0480
Practice Address - Fax:480-832-0490
Is Sole Proprietor?:No
Enumeration Date:2015-04-07
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ55873208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program