Provider Demographics
NPI:1922887603
Name:STOCKARD, SPENCER CLAY (PA-C)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:CLAY
Last Name:STOCKARD
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 1:4890 LUNSFORD MILL RD
Mailing Address - Street 2:
Mailing Address - City:HILTONS
Mailing Address - State:VA
Mailing Address - Zip Code:24258-6005
Mailing Address - Country:US
Mailing Address - Phone:276-690-0936
Mailing Address - Fax:
Practice Address - Street 1:1 WYOMING ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2722
Practice Address - Country:US
Practice Address - Phone:937-208-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-22
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.008405RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant