Provider Demographics
NPI:1487907440
Name:ROWLAND, SPENCER O (PA)
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:O
Last Name:ROWLAND
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 1:6635 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-2354
Mailing Address - Country:US
Mailing Address - Phone:770-968-1323
Mailing Address - Fax:770-968-4556
Practice Address - Street 1:6635 LAKE DR
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-2354
Practice Address - Country:US
Practice Address - Phone:770-968-1323
Practice Address - Fax:770-968-4556
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006623363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003129131AMedicaid
GA003129131BMedicaid
GA003129131AMedicaid