Provider Demographics
NPI:1891271151
Name:MINNICH, SPENCER (PA-C)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:
Last Name:MINNICH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SPENCER
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:QMHC
Mailing Address - Street 1:2012 GARFIELD AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-2541
Mailing Address - Country:US
Mailing Address - Phone:304-893-9090
Mailing Address - Fax:304-893-9113
Practice Address - Street 1:2012 GARFIELD AVE STE 2
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-2541
Practice Address - Country:US
Practice Address - Phone:304-893-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
WV2788363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst