Basic Information
| Provider Information | |||||||||
| NPI: | 1154638658 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPARTA | ||||||||
| FirstName: | VANESSA | ||||||||
| MiddleName: | |||||||||
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| Credential: | P.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WIESZUN | ||||||||
| OtherFirstName: | VANESSA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9312 TEN POINT CT | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218112720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9732712882 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9714 HEALTHWAY DR | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218111154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106413340 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2010 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | C04309 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.