Provider Demographics
NPI:1275071516
Name:SPARKS, TESSA
Entity Type:Individual
Prefix:
First Name:TESSA
Middle Name:
Last Name:SPARKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 31 BOX 310
Mailing Address - Street 2:
Mailing Address - City:DEER
Mailing Address - State:AR
Mailing Address - Zip Code:72628
Mailing Address - Country:US
Mailing Address - Phone:870-428-5391
Mailing Address - Fax:870-428-5392
Practice Address - Street 1:HC 31
Practice Address - Street 2:BOX 310
Practice Address - City:DEER
Practice Address - State:AR
Practice Address - Zip Code:72628
Practice Address - Country:US
Practice Address - Phone:870-428-5391
Practice Address - Fax:870-428-5392
Is Sole Proprietor?:No
Enumeration Date:2017-02-07
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005003363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR566466OtherBCBS
AR5B477OtherMEDICARE
AR150794749Medicaid
ARDA1111OtherRAILROAD MEDICARE
AR222932758Medicaid