Provider Demographics
NPI:1699165613
Name:ELLIOTT, SPENCER LEE (PA-C)
Entity type:Individual
Prefix:MR
First Name:SPENCER
Middle Name:LEE
Last Name:ELLIOTT
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 1:2222 S 16TH ST
Mailing Address - Street 2:TOWER A SUITE 240
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68502-3796
Mailing Address - Country:US
Mailing Address - Phone:402-323-7260
Mailing Address - Fax:402-343-7266
Practice Address - Street 1:2222 S 16TH ST
Practice Address - Street 2:TOWER A SUITE 240
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68502-3796
Practice Address - Country:US
Practice Address - Phone:402-323-7260
Practice Address - Fax:402-323-7266
Is Sole Proprietor?:No
Enumeration Date:2015-01-28
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1884363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS057379004Medicare PIN
NE271431004Medicare PIN