Provider Demographics
NPI:1659466811
Name:SPENCER, PENNY L (CFNP)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:L
Last Name:SPENCER
Suffix:
Gender:F
Credentials:CFNP
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 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-5356
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:PMG EMERGENCY MEDICINE
Practice Address - Street 2:1101 CENTRAL SE
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106
Practice Address - Country:US
Practice Address - Phone:505-841-1125
Practice Address - Fax:505-841-1737
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR28449207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000G9175Medicaid
N/AMedicare PIN
NM000G9175Medicaid