Basic Information
| Provider Information | |||||||||
| NPI: | 1366407181 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPENCER | ||||||||
| FirstName: | MARK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1608 ROAD 44 | ||||||||
| Address2: | |||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993012667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095439820 | ||||||||
| FaxNumber: | 5095456275 | ||||||||
| Practice Location | |||||||||
| Address1: | 1608 ROAD 44 | ||||||||
| Address2: | |||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993012667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095439820 | ||||||||
| FaxNumber: | 5095456275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 03/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD164782 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD00022856 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1366407181 | 05 | WA | MEDICAID | 263783 | 01 | WA | LABOR & INDUSTRIES | OTHER | R07056 | 01 | REGENCE BLUE SHIELD | OTHER |