Provider Demographics
NPI:1164048922
Name:SPENCER, KATELYN MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:MARIE
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 1:203 MADRONA WAY NE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-1928
Mailing Address - Country:US
Mailing Address - Phone:715-892-7107
Mailing Address - Fax:
Practice Address - Street 1:3100 NW BUCKLIN HILL RD STE 202
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8362
Practice Address - Country:US
Practice Address - Phone:360-377-3776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA.PA.61067606363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant