Healthcare Provider Details

I. General information

NPI: 1487626958
Provider Name (Legal Business Name): IAN ALLEN MCLEOD PA-C, ATC, NCTMB
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 10/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15810 S 45TH ST SUITE 101
PHOENIX AZ
85048-7694
US

IV. Provider business mailing address

15810 S 45TH ST SUITE 101
PHOENIX AZ
85048-7694
US

V. Phone/Fax

Practice location:
  • Phone: 480-222-3384
  • Fax: 480-222-3422
Mailing address:
  • Phone: 480-222-3384
  • Fax: 480-222-3422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0364
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4246
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: