Provider Demographics
NPI:1356869549
Name:SPENCER, KENNETH LLOYD JR (PA)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:LLOYD
Last Name:SPENCER
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:815 PECAN GROVE RD E
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75090-1768
Mailing Address - Country:US
Mailing Address - Phone:903-892-2126
Mailing Address - Fax:
Practice Address - Street 1:815 PECAN GROVE RD E
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090-1768
Practice Address - Country:US
Practice Address - Phone:903-892-2126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220047598Medicaid