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General NPI Number Information
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NPI Number | 1912414624
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Entity Type | Individual
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Provider Name | MARISSA BLAIRE SPENCER PA-C
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Gender | Female
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Dates
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Enumeration Date | 01/03/2018
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Last Update Date | 10/28/2021
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Provider Practice Location Address
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Address Line | 5470 W LOVERS LN STE 330
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City | DALLAS
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State | TX
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Zip | 75209-4392
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Country | US
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Telephone | 214-956-7520
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Fax |
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Provider Business Mailing Address
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Address Line | 5470 W LOVERS LN STE 330
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City | DALLAS
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State | TX
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Zip | 75209-4392
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Country | US
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Telephone | 214-956-7337
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Fax | 469-364-8724
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA11743
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License Number State | TX
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