Provider Demographics
NPI:1417587007
Name:SPENCER, RANDI (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:
Last Name:SPENCER
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 N 1100 W
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-3314
Mailing Address - Country:US
Mailing Address - Phone:435-219-1190
Mailing Address - Fax:
Practice Address - Street 1:5699 CROOKED STICK DR
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-7141
Practice Address - Country:US
Practice Address - Phone:970-800-3035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAT.0002099207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine