Provider Demographics
NPI:1518994813
Name:SPARKS, BRENT ALAN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:ALAN
Last Name:SPARKS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4215 CARRIAGE LN
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47805-8628
Mailing Address - Country:US
Mailing Address - Phone:812-239-2707
Mailing Address - Fax:812-231-4675
Practice Address - Street 1:1421 N 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-1005
Practice Address - Country:US
Practice Address - Phone:812-231-4608
Practice Address - Fax:812-231-4675
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28115785A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200344100 AMedicaid
INP23992Medicare UPIN
IN200344100 AMedicaid