Provider Demographics
NPI:1851854897
Name:SQUIRE, SPENSER RYAN (MD)
Entity Type:Individual
Prefix:
First Name:SPENSER
Middle Name:RYAN
Last Name:SQUIRE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9450 S 1300 E STE 210
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-5555
Mailing Address - Country:US
Mailing Address - Phone:801-501-2123
Mailing Address - Fax:801-501-2124
Practice Address - Street 1:9450 S 1300 E STE 210
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-5555
Practice Address - Country:US
Practice Address - Phone:801-501-2123
Practice Address - Fax:801-501-2124
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-08
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12767284-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty