Healthcare Provider Details

I. General information

NPI: 1487581112
Provider Name (Legal Business Name): COLLIN MCCLELLAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15260 W MCDOWELL RD
GOODYEAR AZ
85395-2530
US

IV. Provider business mailing address

17722 N 79TH AVE APT 2125
GLENDALE AZ
85308-8680
US

V. Phone/Fax

Practice location:
  • Phone: 623-207-7838
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: