Provider Demographics
NPI:1033114517
Name:SPENCER, MARK K (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:K
Last Name:SPENCER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 670
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97709-0670
Mailing Address - Country:US
Mailing Address - Phone:541-706-5777
Mailing Address - Fax:541-429-6642
Practice Address - Street 1:1247 NE MEDICAL CENTER DR STE C
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3786
Practice Address - Country:US
Practice Address - Phone:541-706-5777
Practice Address - Fax:541-429-6642
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00617363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORS72219Medicare UPIN
OR103219Medicare ID - Type Unspecified