Provider Demographics
NPI:1760617039
Name:SPENCER, ANDREW O (CRNA)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:O
Last Name:SPENCER
Suffix:
Gender:M
Credentials:CRNA
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 678431
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8431
Mailing Address - Country:US
Mailing Address - Phone:979-245-2677
Mailing Address - Fax:
Practice Address - Street 1:720 AVENUE F N
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:TX
Practice Address - Zip Code:77414-9573
Practice Address - Country:US
Practice Address - Phone:979-245-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-15
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX710567367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX202091903Medicaid