Healthcare Provider Details

I. General information

NPI: 1467502195
Provider Name (Legal Business Name): JEREMY SPENCER KCSA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 01/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 STILESVILLE RD
SCIENCE HILL KY
42553-7410
US

IV. Provider business mailing address

420 STILESVILLE RD
SCIENCE HILL KY
42553-7410
US

V. Phone/Fax

Practice location:
  • Phone: 606-219-0900
  • Fax: 606-451-0177
Mailing address:
  • Phone: 606-219-0900
  • Fax: 606-451-0177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberSA093
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: