Provider Demographics
NPI:1942887757
Name:SPENCER, FABIAN T
Entity Type:Individual
Prefix:
First Name:FABIAN
Middle Name:T
Last Name:SPENCER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-0160
Mailing Address - Country:US
Mailing Address - Phone:154-196-6983
Mailing Address - Fax:
Practice Address - Street 1:46314 TIMINE WAY
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-9417
Practice Address - Country:US
Practice Address - Phone:541-966-9830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-26
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000104602175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist