Healthcare Provider Details

I. General information

NPI: 1023397940
Provider Name (Legal Business Name): CHRISTIAN LEE SPENCER P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2011
Last Update Date: 11/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1369 N 10TH AVE
STAYTON OR
97383-2037
US

IV. Provider business mailing address

1369 N 10TH AVE
STAYTON OR
97383-2037
US

V. Phone/Fax

Practice location:
  • Phone: 503-769-8470
  • Fax:
Mailing address:
  • Phone: 503-769-8470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00259300
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA168445
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: