Provider Demographics
NPI:1700276631
Name:SPRAGUE, ALISSA (MO LIC # 2015005070)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:
Last Name:SPRAGUE
Suffix:
Gender:F
Credentials:MO LIC # 2015005070
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Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 N NEW BALLAS RD STE 175
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6884
Mailing Address - Country:US
Mailing Address - Phone:314-786-2663
Mailing Address - Fax:
Practice Address - Street 1:555 N NEW BALLAS RD STE 175
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6884
Practice Address - Country:US
Practice Address - Phone:314-786-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-30
Last Update Date:2023-01-28
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant