Healthcare Provider Details

I. General information

NPI: 1699734350
Provider Name (Legal Business Name): DAVID T SPARKS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 11/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 S ASH ST
NEVADA MO
64772-3223
US

IV. Provider business mailing address

800 S ASH ST
NEVADA MO
64772-3224
US

V. Phone/Fax

Practice location:
  • Phone: 417-667-3355
  • Fax: 816-461-6586
Mailing address:
  • Phone: 417-882-6744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number096000
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: