Healthcare Provider Details

I. General information

NPI: 1477005411
Provider Name (Legal Business Name): JOSH SPENCER BA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 10/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 GROTTO ST N
SAINT PAUL MN
55104-1754
US

IV. Provider business mailing address

500 GROTTO ST N
SAINT PAUL MN
55104-1754
US

V. Phone/Fax

Practice location:
  • Phone: 651-760-3236
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number264457487
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number1071447
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: