Provider Demographics
NPI:1588938260
Name:MCLEAN, GINA O (PA)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:O
Last Name:MCLEAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11244 SW 133RD TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-8317
Mailing Address - Country:US
Mailing Address - Phone:305-562-5535
Mailing Address - Fax:
Practice Address - Street 1:7001 SW 97TH AVE STE 101
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173
Practice Address - Country:US
Practice Address - Phone:305-273-7998
Practice Address - Fax:305-273-7275
Is Sole Proprietor?:No
Enumeration Date:2012-02-28
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106250363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007655200Medicaid