Provider Demographics
NPI:1841915394
Name:DEROS, SPENCER EMERSON (PA-C)
Entity type:Individual
Prefix:MR
First Name:SPENCER
Middle Name:EMERSON
Last Name:DEROS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 LISBON ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795-2669
Mailing Address - Country:US
Mailing Address - Phone:860-274-6653
Mailing Address - Fax:
Practice Address - Street 1:595 STRAITS TPKE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:CT
Practice Address - Zip Code:06795-3393
Practice Address - Country:US
Practice Address - Phone:844-482-7285
Practice Address - Fax:203-502-2615
Is Sole Proprietor?:No
Enumeration Date:2022-10-06
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5918363A00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant