Provider Demographics
NPI:1538704820
Name:WENZEL, SPENCER DAVID
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:DAVID
Last Name:WENZEL
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 1:1265 HWY 54 WEST
Mailing Address - Street 2:SUITES 102 AND 308
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214
Mailing Address - Country:US
Mailing Address - Phone:770-460-1900
Mailing Address - Fax:
Practice Address - Street 1:1265 HIGHWAY 54 W STE 102
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4537
Practice Address - Country:US
Practice Address - Phone:770-460-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-11
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9716363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty