Provider Demographics
NPI:1609547173
Name:SPAK, BRYCE ALLEN (PA)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:ALLEN
Last Name:SPAK
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 1:2410 OAKWOOD HILLS DR APT 307
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17055-5917
Mailing Address - Country:US
Mailing Address - Phone:814-659-1160
Mailing Address - Fax:
Practice Address - Street 1:503 N 21ST ST
Practice Address - Street 2:
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011-2204
Practice Address - Country:US
Practice Address - Phone:717-763-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-24
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA062667207PE0004X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Single Specialty