=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679050611
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SPENCER SMITH PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2018
-----------------------------------------------------
Last Update Date | 08/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4565 US HIGHWAY 17 STE 106
-----------------------------------------------------
City | FLEMING ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32003-4822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-269-4559
-----------------------------------------------------
Fax | 904-269-4597
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 425 W COLONIAL DR STE 303
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32804-6863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 833-702-8383
-----------------------------------------------------
Fax | 689-304-0303
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA9120420
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA9120420
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------