Provider Demographics
NPI:1104161025
Name:SPENCER, ROBERT DALE (PA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:DALE
Last Name:SPENCER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 DR MICHAEL DEBAKEY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5724
Mailing Address - Country:US
Mailing Address - Phone:337-312-8360
Mailing Address - Fax:337-312-6711
Practice Address - Street 1:277 N HIGHWAY 171 STE 8
Practice Address - Street 2:
Practice Address - City:MOSS BLUFF
Practice Address - State:LA
Practice Address - Zip Code:70611-5374
Practice Address - Country:US
Practice Address - Phone:337-312-0030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-04
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200598363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2322885Medicaid
LA276885YH5NMedicare PIN
LA2322885Medicaid