Healthcare Provider Details

I. General information

NPI: 1780490235
Provider Name (Legal Business Name): ALEXIS IRENE MCCLURE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2024
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 N BROADWAY
PERU IN
46970-1027
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-569-2120
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number99999999999
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10005026A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: