Provider Demographics
NPI:1679889521
Name:MACLELLAN, JOSEPH (PA-C)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:MACLELLAN
Suffix:
Gender:M
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 1:622 YARMOUTH DR
Mailing Address - Street 2:
Mailing Address - City:BAY VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44140-1755
Mailing Address - Country:US
Mailing Address - Phone:440-334-7777
Mailing Address - Fax:
Practice Address - Street 1:5700 COOPER FOSTER PARK RD W
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-4152
Practice Address - Country:US
Practice Address - Phone:440-204-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-28
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003170RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0000Medicaid