MEDICARE: SHEENA CLEGG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	MA066732	PA

General Provider Information

NPI Number	:	1922983931
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHEENA CLEGG

Provider Business Mailing Address
First Line	:	3404 COTTMAN AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19149-1604
Country	:	US
Telephone Number	:	267-977-1616
Fax Number	:

Provider Business Practice Location Address
First Line	:	2329 COTTMAN AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19149-1003
Country	:	US
Telephone Number	:	267-977-1616
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2025
Last Update Date	:	08/08/2025

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