Individual
MR. KELLY L. SPARKS
Active
Individual
MR. KELLY L. SPARKS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
10000928A
IN
363A00000X
Physician Assistant
85080096
IL
363AM0700X
Medical Physician Assistant
0110007007
VA
363AS0400X
Surgical Physician Assistant
Primary
—
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0110007007
STATE LICENSE
VA
01
—
VVX692A
MEDICARE
VA
Enumeration date
02/17/2006
Last updated
08/06/2020
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