Provider Demographics
NPI:1780490235
Name:MCCLURE, ALEXIS IRENE (PA)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:IRENE
Last Name:MCCLURE
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 N BROADWAY
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1027
Practice Address - Country:US
Practice Address - Phone:260-569-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-09
Last Update Date:2025-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN99999999999208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program