Provider Demographics
NPI:1578237574
Name:SPENCER, ISAAC PAUL (DPT)
Entity Type:Individual
Prefix:
First Name:ISAAC
Middle Name:PAUL
Last Name:SPENCER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 BRAMPTON CT
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-4482
Mailing Address - Country:US
Mailing Address - Phone:336-413-9029
Mailing Address - Fax:
Practice Address - Street 1:326 CENTER AVE STE 100
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-7302
Practice Address - Country:US
Practice Address - Phone:907-486-4042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK181441225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist