Healthcare Provider Details

I. General information

NPI: 1366290876
Provider Name (Legal Business Name): CALVIN SPARKS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2024
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N PICKAWAY ST
CIRCLEVILLE OH
43113-1447
US

IV. Provider business mailing address

6506 YACCA WAY
CANAL WINCHESTER OH
43110-8615
US

V. Phone/Fax

Practice location:
  • Phone: 740-474-2126
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0021028
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: