Basic Information
| Provider Information | |||||||||
| NPI: | 1205553617 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHUPE | ||||||||
| FirstName: | SPENCER | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | APNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 936 KRONENWETTER DR APT 5 | ||||||||
| Address2: | |||||||||
| City: | KRONENWETTER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544556215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153213321 | ||||||||
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| Practice Location | |||||||||
| Address1: | 272 CHRISTY ST | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544069390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158245151 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2022 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 13166 | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.