Healthcare Provider Details

I. General information

NPI: 1659242493
Provider Name (Legal Business Name): IAN MCCLUSKEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2025
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11335 SSG SIMS ST
APO AA
79934
US

IV. Provider business mailing address

11335 SSG SIMS ST
APO AA
79934
US

V. Phone/Fax

Practice location:
  • Phone: 915-742-2273
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2024028567
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: