Individual
MR. KELLY L. SPARKS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
109 BRIDGE ST STE 300, DANVILLE, VA 24541-1222
(434) 793-4711
(434) 797-2514
Mailing address
109 BRIDGE ST STE 300, DANVILLE, VA 24541-1222
(434) 793-4711
(434) 797-2514
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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