Provider Demographics
NPI:1598943284
Name:SPENCER, JAMES MERLE (CRNA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MERLE
Last Name:SPENCER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633D MEDICAL GROUP
Mailing Address - Street 2:
Mailing Address - City:LANGLEY AFB
Mailing Address - State:VA
Mailing Address - Zip Code:23665-2040
Mailing Address - Country:US
Mailing Address - Phone:757-764-6747
Mailing Address - Fax:
Practice Address - Street 1:633D MEDICAL GROUP
Practice Address - Street 2:
Practice Address - City:LANGLEY AFB
Practice Address - State:VA
Practice Address - Zip Code:23665-2040
Practice Address - Country:US
Practice Address - Phone:757-764-6747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-05
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX746683367500000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program