Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 56640 | MN |
NPI | 1003173469 |
---|---|
Provider Name | Elisabeth Jean Mcclean |
First Address | St Louis Park, MN 55416-2527 |
Second Address | St Louis Park, MN 55416-2527 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/04/2012 |
Last Update Date | 11/12/2019 |