Healthcare Provider Details

I. General information

NPI: 1174736540
Provider Name (Legal Business Name): SHAWN PATRICK SPARKS A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15012 LEMOYNE BLVD
BILOXI MS
39532-5205
US

IV. Provider business mailing address

1633 S. 11TH ST.
OCEAN SPRINGS MS
39564
US

V. Phone/Fax

Practice location:
  • Phone: 228-396-1285
  • Fax: 228-396-9562
Mailing address:
  • Phone: 228-875-5833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT0312
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: