Provider Demographics
NPI:1043297534
Name:SPENCER, KATHLEEN C (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:C
Last Name:SPENCER
Suffix:
Gender:F
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 1:300 LAKE DR E
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-9302
Mailing Address - Country:US
Mailing Address - Phone:952-993-4327
Mailing Address - Fax:952-993-4320
Practice Address - Street 1:300 LAKE DR E
Practice Address - Street 2:
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-9302
Practice Address - Country:US
Practice Address - Phone:952-993-4327
Practice Address - Fax:952-993-4320
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9408363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical