Basic Information
Provider Information | |||||||||
NPI: | 1144671371 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SPENCER | ||||||||
FirstName: | KRISTYN | ||||||||
MiddleName: | JOELLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CUOMO | ||||||||
OtherFirstName: | KRISTYN | ||||||||
OtherMiddleName: | JOELLE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 99 E STATE ST | ||||||||
Address2: |   | ||||||||
City: | GLOVERSVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 120781203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5187735690 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 99 E STATE ST | ||||||||
Address2: |   | ||||||||
City: | GLOVERSVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 120781203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5187735690 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/29/2016 | ||||||||
LastUpdateDate: | 09/12/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/24/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 019751-1 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.