Provider Demographics
NPI:1366407181
Name:SPENCER, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SPENCER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 ROAD 44
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-2667
Mailing Address - Country:US
Mailing Address - Phone:509-543-9820
Mailing Address - Fax:509-545-6275
Practice Address - Street 1:1608 ROAD 44
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-2667
Practice Address - Country:US
Practice Address - Phone:509-543-9820
Practice Address - Fax:509-545-6275
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD164782207Q00000X
WAMD00022856207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1366407181Medicaid
WA263783OtherLABOR & INDUSTRIES
R07056OtherREGENCE BLUE SHIELD
A21754Medicare UPIN
WAG8892552Medicare PIN