Provider Demographics
NPI:1649334475
Name:SPARKS, LISA ANN (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANN
Last Name:SPARKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:9500 E IRONWOOD SQUARE DR STE 125
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-4582
Mailing Address - Country:US
Mailing Address - Phone:480-626-2552
Mailing Address - Fax:480-626-2551
Practice Address - Street 1:20045 N. 19TH AVENUE
Practice Address - Street 2:BLDG 10, SUITE 3
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-3207
Practice Address - Country:US
Practice Address - Phone:480-626-2552
Practice Address - Fax:480-626-2551
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13545207R00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ235326Medicaid
E34696Medicare UPIN
Z102641Medicare ID - Type Unspecified