Provider Demographics
NPI:1316922123
Name:SPENCER, JUDY MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:MARIE
Last Name:SPENCER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JUDY
Other - Middle Name:MARIE
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:400 FAIRVIEW HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-9308
Mailing Address - Country:US
Mailing Address - Phone:304-872-8545
Mailing Address - Fax:304-872-0675
Practice Address - Street 1:400 FAIRVIEW HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-9308
Practice Address - Country:US
Practice Address - Phone:304-872-8545
Practice Address - Fax:304-872-0675
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV778363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001771978OtherMS BCBS
WV3810000489Medicaid
WVD518361Medicare PIN
WVP76134Medicare UPIN
WV511827Medicare Oscar/Certification
WV511897Medicare Oscar/Certification
WV3810000489Medicaid
WVPA20281Medicare PIN
WV5118271Medicare PIN