MEDICARE: MR. KENNETH LLOYD SPENCER JR. PA

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	363AM0700X	Medical Physician Assistant

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356869549
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KENNETH LLOYD SPENCER JR. PA

Provider Business Mailing Address
First Line	:	815 PECAN GROVE RD E
Second Line	:
City	:	SHERMAN
State	:	TX
Zip	:	75090-1768
Country	:	US
Telephone Number	:	903-892-2126
Fax Number	:

Provider Business Practice Location Address
First Line	:	815 PECAN GROVE RD E
Second Line	:
City	:	SHERMAN
State	:	TX
Zip	:	75090-1768
Country	:	US
Telephone Number	:	903-892-2126
Fax Number	:

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

Provider Enumeration Date	:	09/07/2017
Last Update Date	:	07/21/2022

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