Provider Demographics
NPI:1770559825
Name:CAMPBELL, SPENCER A (PA)
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:A
Last Name:CAMPBELL
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 1:900 OAKMONT LANE
Mailing Address - Street 2:
Mailing Address - City:OAKMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-2452
Mailing Address - Country:US
Mailing Address - Phone:630-734-0200
Mailing Address - Fax:414-423-4134
Practice Address - Street 1:2901 W KINNICKINNIC RIVER PKWY
Practice Address - Street 2:SUITE 201
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3677
Practice Address - Country:US
Practice Address - Phone:414-385-8700
Practice Address - Fax:414-385-2799
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1558-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42954900Medicaid
WIR97944Medicare UPIN
WI0016Medicare ID - Type Unspecified
WI003765240Medicare PIN