Provider Demographics
NPI:1174859730
Name:PACKER, SPENCER DAYTON
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:DAYTON
Last Name:PACKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 W POPLAR AVE
Mailing Address - Street 2:C/O FAMILY HEALTHCARE NETWORK
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257-5839
Mailing Address - Country:US
Mailing Address - Phone:559-781-7242
Mailing Address - Fax:559-793-3574
Practice Address - Street 1:1107 W POPLAR AVE
Practice Address - Street 2:C/O FAMILY HEALTHCARE NETWORK
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-5839
Practice Address - Country:US
Practice Address - Phone:559-781-7242
Practice Address - Fax:559-793-3174
Is Sole Proprietor?:No
Enumeration Date:2009-11-02
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA23178363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical