=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770762353
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WANDA J. SPENCER, M.D., A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2007
-----------------------------------------------------
Last Update Date | 12/20/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 E. CHAPEL ST. SUITE #2
-----------------------------------------------------
City | SANTA MARIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93454-4607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-922-9600
-----------------------------------------------------
Fax | 805-922-8892
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 E. CHAPEL ST. SUITE #2
-----------------------------------------------------
City | SANTA MARIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93454-4607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-922-9600
-----------------------------------------------------
Fax | 805-922-8892
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. WANDA J. SPENCER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 805-922-9600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | A42254
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------