Provider Demographics
NPI:1205553617
Name:SHUPE, SPENCER ALLEN (APNP)
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:ALLEN
Last Name:SHUPE
Suffix:
Gender:M
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:936 KRONENWETTER DR APT 5
Mailing Address - Street 2:
Mailing Address - City:KRONENWETTER
Mailing Address - State:WI
Mailing Address - Zip Code:54455-6215
Mailing Address - Country:US
Mailing Address - Phone:715-321-3321
Mailing Address - Fax:
Practice Address - Street 1:272 CHRISTY ST
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:WI
Practice Address - Zip Code:54406-9390
Practice Address - Country:US
Practice Address - Phone:715-824-5151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13166363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty