Healthcare Provider Details

I. General information

NPI: 1316677578
Provider Name (Legal Business Name): SPENCER DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2022
Last Update Date: 12/09/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

762 14TH ST
ELKO NV
89801-3413
US

IV. Provider business mailing address

762 14H ST
ELKO NV
89801
US

V. Phone/Fax

Practice location:
  • Phone: 775-738-1553
  • Fax:
Mailing address:
  • Phone: 775-738-1553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA0579
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: