Basic Information
| Provider Information | |||||||||
| NPI: | 1033114517 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPENCER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 670 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977090670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417065777 | ||||||||
| FaxNumber: | 5414296642 | ||||||||
| Practice Location | |||||||||
| Address1: | 1247 NE MEDICAL CENTER DR STE C | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977013786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417065777 | ||||||||
| FaxNumber: | 5414296642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA00617 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.