Provider Demographics
NPI:1295361699
Name:SPENCER, DOUGLAS (PA-C)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:SPENCER
Suffix:
Gender:M
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 1:17TH S AND C ST
Mailing Address - Street 2:
Mailing Address - City:JBLM
Mailing Address - State:WA
Mailing Address - Zip Code:98433
Mailing Address - Country:US
Mailing Address - Phone:253-969-1991
Mailing Address - Fax:
Practice Address - Street 1:11582 C ST
Practice Address - Street 2:
Practice Address - City:JOINT BASE LEWIS-MCCHORD
Practice Address - State:WA
Practice Address - Zip Code:98433
Practice Address - Country:US
Practice Address - Phone:253-966-1991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-17
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61040872363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant