Provider Demographics
NPI:1588125397
Name:MCCLANE, NATHAN (MD, MA)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:MCCLANE
Suffix:
Gender:M
Credentials:MD, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16772 W BELL RD STE 110-619
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-9702
Mailing Address - Country:US
Mailing Address - Phone:909-632-3409
Mailing Address - Fax:
Practice Address - Street 1:720 E THUNDERBIRD RD STE 3
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-5396
Practice Address - Country:US
Practice Address - Phone:480-531-1681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-26
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ72686208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program