Healthcare Provider Details

I. General information

NPI: 1417949082
Provider Name (Legal Business Name): PICCINA R SPENCE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 10/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

192 LINDQUIST RD BLD 412, TFCMC
FT STEWART GA
31314-5122
US

IV. Provider business mailing address

1061 HARMON AVE, SUITE 1D03 WINN ARMY COMMUNITY HOSPITAL
FT. STEWART GA
31315
US

V. Phone/Fax

Practice location:
  • Phone: 912-435-6633
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number02958
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: