Provider Demographics
NPI:1952637282
Name:SPENCER, DARIUS TERRENCE (PA)
Entity Type:Individual
Prefix:
First Name:DARIUS
Middle Name:TERRENCE
Last Name:SPENCER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4360 OREGON ST APT 2
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-7832
Mailing Address - Country:US
Mailing Address - Phone:619-280-3806
Mailing Address - Fax:
Practice Address - Street 1:4360 OREGON ST APT 2
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-7832
Practice Address - Country:US
Practice Address - Phone:619-280-3806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-21
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20625363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant