Provider Demographics
NPI:1518468511
Name:EGAN, SPENCER BROCK
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:BROCK
Last Name:EGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:971 S 800 W
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-3042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1755 N 200 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1915
Practice Address - Country:US
Practice Address - Phone:435-753-6242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-24
Last Update Date:2018-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker