Basic Information
| Provider Information | |||||||||
| NPI: | 1770559825 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | SPENCER | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 OAKMONT LANE | ||||||||
| Address2: | |||||||||
| City: | OAKMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605592452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307340200 | ||||||||
| FaxNumber: | 4144234134 | ||||||||
| Practice Location | |||||||||
| Address1: | 2901 W KINNICKINNIC RIVER PKWY | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532153677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143858700 | ||||||||
| FaxNumber: | 4143852799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1558-023 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 42954900 | 05 | WI | MEDICAID |