Provider Demographics
NPI:1598714230
Name:SPENCE, DAVID AH (PA)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:AH
Last Name:SPENCE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4178 HIGHBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VT
Mailing Address - Zip Code:05454-5446
Mailing Address - Country:US
Mailing Address - Phone:802-524-9595
Mailing Address - Fax:
Practice Address - Street 1:4178 HIGHBRIDGE RD
Practice Address - Street 2:
Practice Address - City:GEORGIA
Practice Address - State:VT
Practice Address - Zip Code:05454-5446
Practice Address - Country:US
Practice Address - Phone:802-524-9595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0550030604363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT2000545Medicaid
VT2000545Medicaid
VTAP1460Medicare PIN