Provider Demographics
NPI:1396139069
Name:SPENCER, KIMBERLY (PA-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SPENCER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:NOELLE
Other - Last Name:KNIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16101 EVANS ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68116-6447
Mailing Address - Country:US
Mailing Address - Phone:402-717-9700
Mailing Address - Fax:402-717-9701
Practice Address - Street 1:16101 EVANS ST
Practice Address - Street 2:SUITE 100
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68116-6447
Practice Address - Country:US
Practice Address - Phone:402-717-9700
Practice Address - Fax:402-717-9701
Is Sole Proprietor?:No
Enumeration Date:2015-03-20
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA076849363AM0700X
NE2014363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical