Healthcare Provider Details

I. General information

NPI: 1598714230
Provider Name (Legal Business Name): DAVID A.H. SPENCE P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 05/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4178 HIGHBRIDGE RD
GEORGIA VT
05454-5446
US

IV. Provider business mailing address

4178 HIGHBRIDGE RD
FAIRFAX VT
05454-5446
US

V. Phone/Fax

Practice location:
  • Phone: 802-524-9595
  • Fax:
Mailing address:
  • Phone: 802-524-9595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0550030604
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: