Healthcare Provider Details

I. General information

NPI: 1114367737
Provider Name (Legal Business Name): SUSAN MCLAREN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN GALLUCCI PA-C

II. Dates (important events)

Enumeration Date: 06/27/2013
Last Update Date: 06/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10909 HANNAN RD
ROMULUS MI
48174-1383
US

IV. Provider business mailing address

45515 MUIRFIELD DR
CANTON MI
48188-1098
US

V. Phone/Fax

Practice location:
  • Phone: 734-941-1142
  • Fax: 734-955-6973
Mailing address:
  • Phone: 734-748-9399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601001901
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: