Healthcare Provider Details

I. General information

NPI: 1144985128
Provider Name (Legal Business Name): NICHOLAS RAY SPEAR PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2021
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16603 JOHN HENRY LN
RAMONA CA
92065-6931
US

IV. Provider business mailing address

PO BOX 176
PALOMAR MOUNTAIN CA
92060-0176
US

V. Phone/Fax

Practice location:
  • Phone: 619-699-9839
  • Fax:
Mailing address:
  • Phone: 619-699-9839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number60313
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: