Provider Demographics
NPI:1821599374
Name:POPP, SPENCER (PA-C)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:
Last Name:POPP
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 1:1105 SIXTH ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2345
Mailing Address - Country:US
Mailing Address - Phone:231-935-7514
Mailing Address - Fax:231-392-0039
Practice Address - Street 1:4045 W ROYAL DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-8965
Practice Address - Country:US
Practice Address - Phone:231-935-0900
Practice Address - Fax:231-935-0308
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008584363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant