Healthcare Provider Details

I. General information

NPI: 1962963611
Provider Name (Legal Business Name): SPENCER OLE MOEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 SENTARA CIR STE 201A
WILLIAMSBURG VA
23188-5716
US

IV. Provider business mailing address

400 SENTARA CIR STE 201A
WILLIAMSBURG VA
23188-5716
US

V. Phone/Fax

Practice location:
  • Phone: 757-827-2127
  • Fax: 757-827-2255
Mailing address:
  • Phone: 757-827-2127
  • Fax: 757-827-2255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number0101276458
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number0101276458
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: