Healthcare Provider Details

I. General information

NPI: 1790884435
Provider Name (Legal Business Name): WANDA W MCLURE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MOUNT EUSTIS RD
LITTLETON NH
03561-3712
US

IV. Provider business mailing address

34 PILGRIM DR
LITTLETON NH
03561-3950
US

V. Phone/Fax

Practice location:
  • Phone: 603-444-2464
  • Fax: 603-444-3441
Mailing address:
  • Phone: 603-444-6215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0342P
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: