Provider Demographics
NPI:1033481296
Name:SPENCER, MANDY MARIE (PAC)
Entity Type:Individual
Prefix:MRS
First Name:MANDY
Middle Name:MARIE
Last Name:SPENCER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:MARIE
Other - Last Name:ERWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:7 WATER ST
Mailing Address - Street 2:
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901-1126
Mailing Address - Country:US
Mailing Address - Phone:570-724-1010
Mailing Address - Fax:
Practice Address - Street 1:236 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:PA
Practice Address - Zip Code:16950-1607
Practice Address - Country:US
Practice Address - Phone:814-367-5911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-03
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055361363A00000X, 363AM0700X
MDC04670363AS0400X
NY018456363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical