Provider Demographics
NPI:1063273019
Name:SPARKS, MATTHEW NATHAN (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:NATHAN
Last Name:SPARKS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:MATTHEW
Other - Middle Name:NATHAN
Other - Last Name:SPARKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1326
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75671-1326
Mailing Address - Country:US
Mailing Address - Phone:903-927-3782
Mailing Address - Fax:903-927-1764
Practice Address - Street 1:1400 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3536
Practice Address - Country:US
Practice Address - Phone:903-791-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA17731363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA17731OtherTX PA LICENSE