Provider Demographics
NPI:1043592777
Name:SPARKS, EMILY LOUISE (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:LOUISE
Last Name:SPARKS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:LOUISE
Other - Last Name:DANNISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1900 44TH ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508
Mailing Address - Country:US
Mailing Address - Phone:616-685-8620
Mailing Address - Fax:616-447-7674
Practice Address - Street 1:1471 EAST BELTLINE NE
Practice Address - Street 2:STE 201
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-685-8620
Practice Address - Fax:616-447-7674
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MI5601006851363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI3233380Medicare PIN