Provider Demographics
NPI:1689907362
Name:SPARKS, BRIAN WAYNE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:WAYNE
Last Name:SPARKS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 GATOR CV
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-8219
Mailing Address - Country:US
Mailing Address - Phone:318-208-2029
Mailing Address - Fax:
Practice Address - Street 1:407 GATOR CV
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-8219
Practice Address - Country:US
Practice Address - Phone:318-208-2029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-11
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200306363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant