Provider Demographics
NPI:1780194696
Name:STANGER, SPENCER (NP)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:
Last Name:STANGER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 RIGBY LAKE DR STE 115
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5230
Mailing Address - Country:US
Mailing Address - Phone:208-745-5021
Mailing Address - Fax:208-745-5026
Practice Address - Street 1:711 RIGBY LAKE DR STE 115
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-5230
Practice Address - Country:US
Practice Address - Phone:208-745-5021
Practice Address - Fax:208-745-5026
Is Sole Proprietor?:No
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID57005363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily