Provider Demographics
NPI:1306436845
Name:SPARKS, LOGAN (PA)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:SPARKS
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:3815 PELHAM ST STE 13
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3852
Mailing Address - Country:US
Mailing Address - Phone:313-722-4683
Mailing Address - Fax:313-241-9342
Practice Address - Street 1:3815 PELHAM ST STE 13
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3852
Practice Address - Country:US
Practice Address - Phone:313-722-4683
Practice Address - Fax:313-241-9342
Is Sole Proprietor?:No
Enumeration Date:2021-01-19
Last Update Date:2023-03-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601010419363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant