MEDICARE: COLLIN MCCLELLAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		AZ

General Provider Information

NPI Number	:	1487581112
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLIN MCCLELLAN

Provider Business Mailing Address
First Line	:	17722 N 79TH AVE APT 2125
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308-8680
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	15260 W MCDOWELL RD
Second Line	:
City	:	GOODYEAR
State	:	AZ
Zip	:	85395-2530
Country	:	US
Telephone Number	:	623-207-7838
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/06/2026
Last Update Date	:	05/06/2026

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Directions to “ COLLIN MCCLELLAN ” Practice Location

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