Provider Demographics
NPI:1487019634
Name:SPENCER, JOHN (NP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:SPENCER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2422 STUART AVE
Mailing Address - Street 2:APT 2A
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-3414
Mailing Address - Country:US
Mailing Address - Phone:804-307-1355
Mailing Address - Fax:
Practice Address - Street 1:420 E 76TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-3396
Practice Address - Country:US
Practice Address - Phone:212-434-5301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-15
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF401947-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health