Provider Demographics
NPI:1588062939
Name:MCCLUSKY, JOHN OWEN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:OWEN
Last Name:MCCLUSKY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10965 BEN CRENSHAW DR BLDG 1
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79935-3021
Mailing Address - Country:US
Mailing Address - Phone:915-594-4000
Mailing Address - Fax:
Practice Address - Street 1:10965 BEN CRENSHAW DR BLDG 1
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79935-3021
Practice Address - Country:US
Practice Address - Phone:915-594-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-17
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09417363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant