Basic Information
| Provider Information | |||||||||
| NPI: | 1790884435 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCLURE | ||||||||
| FirstName: | WANDA | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34 PILGRIM DR | ||||||||
| Address2: | |||||||||
| City: | LITTLETON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035613950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034446215 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25 MOUNT EUSTIS RD | ||||||||
| Address2: | |||||||||
| City: | LITTLETON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035613712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034442464 | ||||||||
| FaxNumber: | 6034443441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 0342P | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 30333040 | 05 | NH | MEDICAID |