Provider Demographics
NPI:1912414624
Name:SPENCER, MARISSA BLAIRE (PA-C)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:BLAIRE
Last Name:SPENCER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:BLAIRE
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5470 W LOVERS LN STE 330
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75209-4392
Mailing Address - Country:US
Mailing Address - Phone:214-956-7337
Mailing Address - Fax:469-364-8724
Practice Address - Street 1:5470 W LOVERS LN STE 330
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75209-4392
Practice Address - Country:US
Practice Address - Phone:214-956-7520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-03
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11743363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant