Healthcare Provider Details

I. General information

NPI: 1689142440
Provider Name (Legal Business Name): BRIAN TODD SPENCER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2018
Last Update Date: 11/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 N 500 W
PROVO UT
84604-3380
US

IV. Provider business mailing address

6325 W 10150 N
HIGHLAND UT
84003-3453
US

V. Phone/Fax

Practice location:
  • Phone: 801-357-8586
  • Fax: 801-357-7786
Mailing address:
  • Phone: 801-850-2071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9155350-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: