Provider Demographics
NPI:1649398785
Name:SPENCER, BRIAN E (PA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:E
Last Name:SPENCER
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:PO BOX 692
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95763-0692
Mailing Address - Country:US
Mailing Address - Phone:916-647-4821
Mailing Address - Fax:916-896-0699
Practice Address - Street 1:5025 BIRCH VALLEY WAY
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95742-7799
Practice Address - Country:US
Practice Address - Phone:916-647-4821
Practice Address - Fax:916-896-0699
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA916363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVBM364YMedicare UPIN
NVBM364XMedicare UPIN
CAGV7392Medicare PIN
NVBK083BMedicare PIN
NVBK083AMedicare PIN