Provider Demographics
NPI:1700114592
Name:SPARKS, ADRIENNE MICHELLE (PA)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:MICHELLE
Last Name:SPARKS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 UNIVERSITY BLVD
Mailing Address - Street 2:UH 0279
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5149
Mailing Address - Country:US
Mailing Address - Phone:317-944-2968
Mailing Address - Fax:317-944-0887
Practice Address - Street 1:550 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5149
Practice Address - Country:US
Practice Address - Phone:317-278-9729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-07
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99040314A363AM0700X
IN10001151A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN176470LLMedicare PIN
INM400028183Medicare PIN
INP01453377Medicare PIN