Healthcare Provider Details

I. General information

NPI: 1588052666
Provider Name (Legal Business Name): DAN JORDAN SPENCE PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/25/2014
Last Update Date: 12/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3759 VALLEY VIEW RD
AUSTIN TX
78704-5921
US

IV. Provider business mailing address

1015 CEDAR GLN
AUSTIN TX
78745-3043
US

V. Phone/Fax

Practice location:
  • Phone: 512-443-3436
  • Fax:
Mailing address:
  • Phone: 512-416-9018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2106628
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: