Provider Demographics
NPI:1982095618
Name:SPARKS, STEPHANIE (PA-C, ATC, MED, MSPS)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SPARKS
Suffix:
Gender:F
Credentials:PA-C, ATC, MED, MSPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11341 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:OH
Mailing Address - Zip Code:43331-9717
Mailing Address - Country:US
Mailing Address - Phone:614-205-2396
Mailing Address - Fax:
Practice Address - Street 1:500 LONDON AVE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-5512
Practice Address - Country:US
Practice Address - Phone:937-644-6115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-17
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT.0034032255A2300X
OH50.004293363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer