Provider Demographics
NPI:1083202048
Name:SPENCER, PETRA (CRNA)
Entity Type:Individual
Prefix:
First Name:PETRA
Middle Name:
Last Name:SPENCER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:PETRA
Other - Middle Name:
Other - Last Name:GERBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:16211 REDLAND RD
Mailing Address - Street 2:
Mailing Address - City:DERWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:20855-2133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16211 REDLAND RD
Practice Address - Street 2:
Practice Address - City:DERWOOD
Practice Address - State:MD
Practice Address - Zip Code:20855-2133
Practice Address - Country:US
Practice Address - Phone:210-542-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-05
Last Update Date:2023-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9519497163W00000X
MDAC003797367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE