Provider Demographics
NPI:1194195834
Name:ADVANCED PRACTICE ADULT-GERONTOLOGY
Entity Type:Organization
Organization Name:ADVANCED PRACTICE ADULT-GERONTOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:MSN,AGPCP,BC
Authorized Official - Phone:276-768-9058
Mailing Address - Street 1:121 PINEY VIEW LN
Mailing Address - Street 2:
Mailing Address - City:MOUTH OF WILSON
Mailing Address - State:VA
Mailing Address - Zip Code:24363-3694
Mailing Address - Country:US
Mailing Address - Phone:276-768-9058
Mailing Address - Fax:276-783-2879
Practice Address - Street 1:5140 HATCHER RD
Practice Address - Street 2:FAIRVIEW HOME
Practice Address - City:DUBLIN
Practice Address - State:VA
Practice Address - Zip Code:24084-4802
Practice Address - Country:US
Practice Address - Phone:276-431-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0017142291363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty