Healthcare Provider Details

I. General information

NPI: 1174859730
Provider Name (Legal Business Name): SPENCER DAYTON PACKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2009
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 W POPLAR AVE C/O FAMILY HEALTHCARE NETWORK
PORTERVILLE CA
93257-5839
US

IV. Provider business mailing address

1107 W POPLAR AVE C/O FAMILY HEALTHCARE NETWORK
PORTERVILLE CA
93257-5839
US

V. Phone/Fax

Practice location:
  • Phone: 559-781-7242
  • Fax: 559-793-3174
Mailing address:
  • Phone: 559-781-7242
  • Fax: 559-793-3574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA23178
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: