Provider Demographics
NPI:1881192565
Name:SPENCER, ALYSSA MARIE (PA, AT)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MARIE
Last Name:SPENCER
Suffix:
Gender:F
Credentials:PA, AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6480 HARRISON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7961
Mailing Address - Country:US
Mailing Address - Phone:513-713-1779
Mailing Address - Fax:513-854-9921
Practice Address - Street 1:3205 WOODMAN DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420-1143
Practice Address - Country:US
Practice Address - Phone:937-298-4417
Practice Address - Fax:937-298-8260
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
OH50.007371RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0476832Medicaid