Provider Demographics
NPI:1699734350
Name:SPARKS, DAVID T (CRNA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:T
Last Name:SPARKS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 S ASH ST
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-3224
Mailing Address - Country:US
Mailing Address - Phone:417-882-6744
Mailing Address - Fax:
Practice Address - Street 1:800 S ASH ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-3223
Practice Address - Country:US
Practice Address - Phone:417-667-3355
Practice Address - Fax:816-461-6586
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO096000367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO918596701Medicaid
MO718C435Medicare ID - Type Unspecified
MOS30879Medicare UPIN
MO825085236Medicare PIN
MO918596701Medicaid