Provider Demographics
NPI:1033185467
Name:SPENCE, SUSAN R (CRNA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:R
Last Name:SPENCE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 AMBERWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-7016
Mailing Address - Country:US
Mailing Address - Phone:318-572-5292
Mailing Address - Fax:
Practice Address - Street 1:2000 E LAMAR BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76006-7346
Practice Address - Country:US
Practice Address - Phone:682-227-6834
Practice Address - Fax:682-227-6864
Is Sole Proprietor?:No
Enumeration Date:2006-02-25
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX623720367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86211UOtherBCBS
TX181746201Medicaid
TX750818167015OtherTRICARE
TX181746201Medicaid