Basic Information
| Provider Information | |||||||||
| NPI: | 1285020792 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCLEOD | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172504906 | ||||||||
| FaxNumber: | 8172501815 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172504906 | ||||||||
| FaxNumber: | 8172501815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2015 | ||||||||
| LastUpdateDate: | 04/25/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA09191 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 8078NT | 01 | TX | BCBS | OTHER | 351942301 | 05 | TX | MEDICAID |