Provider Demographics
NPI:1407949530
Name:SPENCER, PATRICK G (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:G
Last Name:SPENCER
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4465 WHITE BEAR PARKWAY
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110
Mailing Address - Country:US
Mailing Address - Phone:651-653-0062
Mailing Address - Fax:651-653-0288
Practice Address - Street 1:4465 WHITE BEAR PARKWAY
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110
Practice Address - Country:US
Practice Address - Phone:651-653-0062
Practice Address - Fax:651-653-0288
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR106819-3363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN348618400Medicaid
MN348618400Medicaid
MN500003143Medicare ID - Type Unspecified