Provider Demographics
NPI:1760151112
Name:POSHADLO, SPENCER C (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SPENCER
Middle Name:C
Last Name:POSHADLO
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 1:2032 LENNON ST
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1617
Mailing Address - Country:US
Mailing Address - Phone:248-224-1918
Mailing Address - Fax:
Practice Address - Street 1:36622 FIVE MILE RD STE 101
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1900
Practice Address - Country:US
Practice Address - Phone:734-526-1791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010626363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant