Healthcare Provider Details

I. General information

NPI: 1952006934
Provider Name (Legal Business Name): COLLIN SHANLEY MCLEAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2023
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E NORRIS DR
OTTAWA IL
61350-1604
US

IV. Provider business mailing address

525 HOUSTON ST
OTTAWA IL
61350-3528
US

V. Phone/Fax

Practice location:
  • Phone: 815-433-3100
  • Fax:
Mailing address:
  • Phone: 219-669-3378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085009935
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: