Basic Information
| Provider Information | |||||||||
| NPI: | 1366536104 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPARR | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 824 ILLINOIS AVE | ||||||||
| Address2: | |||||||||
| City: | STEVENS POINT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544813112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153427500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 824 ILLINOIS AVE | ||||||||
| Address2: | |||||||||
| City: | STEVENS POINT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544813112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153427500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 03/02/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 35645 | WI | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 13893 | 01 | DEAN HEALTH PLAN | OTHER | 2013057 | 01 | PHYSICIANS PLUS | OTHER | 35645-20 | 01 | WI | WI STATE LIC | OTHER | 390808509 | 01 | CIGNA | OTHER | 390808509DN | 01 | UNITY | OTHER | 16800226 | 01 | MEDICARE PART B | OTHER | 34110500 | 05 | WI | MEDICAID |