Basic Information
| Provider Information | |||||||||
| NPI: | 1114476140 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCLEAN | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | RUTH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COCCO | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | RUTH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 17500 FEDERAL DR STE 750 | ||||||||
| Address2: | |||||||||
| City: | ALLEN PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481013656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139821370 | ||||||||
| FaxNumber: | 3139821376 | ||||||||
| Practice Location | |||||||||
| Address1: | 17500 FEDERAL DR STE 750 | ||||||||
| Address2: | |||||||||
| City: | ALLEN PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481013656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139821370 | ||||||||
| FaxNumber: | 3139821376 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2016 | ||||||||
| LastUpdateDate: | 04/29/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083X0100X | 5601008938 | MI | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine | 363AM0700X | PA53731 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 5601008938 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.