Healthcare Provider Details

I. General information

NPI: 1568982353
Provider Name (Legal Business Name): JEFFREY SPENCER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2017
Last Update Date: 12/06/2022
Certification Date: 12/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 EVERETT RD
ALBANY NY
12205-1407
US

IV. Provider business mailing address

123 EVERETT RD
ALBANY NY
12205-1407
US

V. Phone/Fax

Practice location:
  • Phone: 518-701-2085
  • Fax: 518-701-2139
Mailing address:
  • Phone: 518-701-2085
  • Fax: 518-701-2139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number020896-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: