Provider Demographics
NPI:1104460096
Name:RICE, SPENCER (PA-C)
Entity type:Individual
Prefix:MR
First Name:SPENCER
Middle Name:
Last Name:RICE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1068 PALAFOX DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-4526
Mailing Address - Country:US
Mailing Address - Phone:918-671-7098
Mailing Address - Fax:
Practice Address - Street 1:1220 CAROLINE ST NE STE A-230
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30307-2749
Practice Address - Country:US
Practice Address - Phone:678-710-3980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-04
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10147363A00000X
FL9112730363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty