Provider Demographics
NPI:1700389798
Name:ANDERSON, SPENCER CHARLES (PA-C)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:CHARLES
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 GRANDE BLUFFS LN
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66503-2481
Mailing Address - Country:US
Mailing Address - Phone:620-376-4221
Mailing Address - Fax:
Practice Address - Street 1:2500 CANTERBURY DR STE 112
Practice Address - Street 2:
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601-2258
Practice Address - Country:US
Practice Address - Phone:785-261-7599
Practice Address - Fax:785-261-7548
Is Sole Proprietor?:No
Enumeration Date:2018-03-15
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0005198363A00000X
KS1502179363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant