Provider Demographics
NPI:1467502195
Name:SPENCER, JEREMY (KCSA)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:
Last Name:SPENCER
Suffix:
Gender:M
Credentials:KCSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 STILESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SCIENCE HILL
Mailing Address - State:KY
Mailing Address - Zip Code:42553-7410
Mailing Address - Country:US
Mailing Address - Phone:606-219-0900
Mailing Address - Fax:606-451-0177
Practice Address - Street 1:420 STILESVILLE RD
Practice Address - Street 2:
Practice Address - City:SCIENCE HILL
Practice Address - State:KY
Practice Address - Zip Code:42553-7410
Practice Address - Country:US
Practice Address - Phone:606-219-0900
Practice Address - Fax:606-451-0177
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2009-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYSA093363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical