MEDICARE: SUSAN R. SPENCE CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	623720	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	86211U	OTHER	TX	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	750818167015	OTHER	TX	TRICARE

General Provider Information

NPI Number	:	1033185467
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN R. SPENCE CRNA

Provider Business Mailing Address
First Line	:	424 AMBERWOOD CIR
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75701-7016
Country	:	US
Telephone Number	:	318-572-5292
Fax Number	:

Provider Business Practice Location Address
First Line	:	2000 E LAMAR BLVD
Second Line	:	SUITE 400
City	:	ARLINGTON
State	:	TX
Zip	:	76006-7346
Country	:	US
Telephone Number	:	682-227-6834
Fax Number	:	682-227-6864

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/25/2006
Last Update Date	:	01/06/2010

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