Provider Demographics
NPI:1093465692
Name:HEGERHORST, SPENCER BRUCE (DO)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:BRUCE
Last Name:HEGERHORST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1085 S BLUFF ST
Mailing Address - Street 2:
Mailing Address - City:SANTAQUIN
Mailing Address - State:UT
Mailing Address - Zip Code:84655-8337
Mailing Address - Country:US
Mailing Address - Phone:503-593-8276
Mailing Address - Fax:
Practice Address - Street 1:902 LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3597
Practice Address - Country:US
Practice Address - Phone:719-557-5872
Practice Address - Fax:719-557-4780
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPENDING207Q00000X
COTL.0009167390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine