Provider Demographics
NPI:1881794659
Name:SPENCER, MARY JO L (CPNP)
Entity type:Individual
Prefix:
First Name:MARY JO
Middle Name:L
Last Name:SPENCER
Suffix:
Gender:F
Credentials:CPNP
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Mailing Address - Street 1:420 DELAWARE STREET SE
Mailing Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-884-0936
Mailing Address - Fax:
Practice Address - Street 1:516 DELAWARE ST SE
Practice Address - Street 2:PWB FOURTH FLOOR, ROOM 4-100
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0356
Practice Address - Country:US
Practice Address - Phone:612-884-0936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNR 086024-0363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN12-13453OtherMEDICA CHOICE
MNHP20941OtherHEALTH PARTNERS
MN05G59SPOtherBLUE CROSS BLUE SHIELD
MN768359OtherARAZ
MN107868OtherUCARE
MN12-13453OtherMEDICA PRIMARY
MT4300179Medicaid
MN131017800Medicaid
MN1015967OtherPREFERRED ONE
MN157941OtherFAIRVIEW