Provider Demographics
NPI:1760833388
Name:MCCLELLAN, KANDACE SUZETTE (PA-C)
Entity type:Individual
Prefix:
First Name:KANDACE
Middle Name:SUZETTE
Last Name:MCCLELLAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N PENNSYLVANIA AVE STE 920
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-4779
Mailing Address - Country:US
Mailing Address - Phone:575-208-2509
Mailing Address - Fax:575-265-1700
Practice Address - Street 1:400 N PENNSYLVANIA AVE STE 920
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4779
Practice Address - Country:US
Practice Address - Phone:575-208-2509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-24
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NMPA2016-0067363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM10601309Medicaid