Provider Demographics
NPI:1376001362
Name:CRAIG, SPENCER LUCILE
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:LUCILE
Last Name:CRAIG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1265 UPPER HEMBREE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-1258
Mailing Address - Country:US
Mailing Address - Phone:770-751-1133
Mailing Address - Fax:770-751-7410
Practice Address - Street 1:1265 UPPER HEMBREE RD STE 100
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1258
Practice Address - Country:US
Practice Address - Phone:770-751-1133
Practice Address - Fax:770-751-7410
Is Sole Proprietor?:No
Enumeration Date:2019-03-08
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9164363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA9164OtherPHYSICIAN ASSISTANT LICENSE