Healthcare Provider Details

I. General information

NPI: 1649245309
Provider Name (Legal Business Name): KELLY L. SPARKS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 BRIDGE ST STE 300
DANVILLE VA
24541-1222
US

IV. Provider business mailing address

109 BRIDGE ST STE 300
DANVILLE VA
24541-1222
US

V. Phone/Fax

Practice location:
  • Phone: 434-793-4711
  • Fax: 434-797-2514
Mailing address:
  • Phone: 434-793-4711
  • Fax: 434-797-2514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110007007
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10000928A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number85080096
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: