Provider Demographics
NPI:1649245309
Name:SPARKS, KELLY L (PA)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:L
Last Name:SPARKS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 BRIDGE ST STE 300
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-1222
Mailing Address - Country:US
Mailing Address - Phone:434-793-4711
Mailing Address - Fax:434-797-2514
Practice Address - Street 1:109 BRIDGE ST STE 300
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-1222
Practice Address - Country:US
Practice Address - Phone:434-793-4711
Practice Address - Fax:434-797-2514
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA363AS0400X
VA0110007007363AM0700X
IN10000928A363A00000X
IL85080096363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVX692AOtherMEDICARE
VA0110007007OtherSTATE LICENSE
ILP38486Medicare UPIN