Basic Information
Provider Information | |||||||||
NPI: | 1427508514 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TONI SPARKS, PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1111 S ORCHARD ST | ||||||||
Address2: | STE 155 | ||||||||
City: | BOISE | ||||||||
State: | ID | ||||||||
PostalCode: | 837051966 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2083330103 | ||||||||
FaxNumber: | 2083330105 | ||||||||
Practice Location | |||||||||
Address1: | 1111 S ORCHARD ST | ||||||||
Address2: | STE 155 | ||||||||
City: | BOISE | ||||||||
State: | ID | ||||||||
PostalCode: | 837051966 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2083330103 | ||||||||
FaxNumber: | 2083330105 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/12/2016 | ||||||||
LastUpdateDate: | 10/12/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SPARKS | ||||||||
AuthorizedOfficialFirstName: | TONI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | NP/OWNER | ||||||||
AuthorizedOfficialTelephone: | 2083330103 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | NP | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP-458A | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | NP-458A | 01 | ID | LICENSE | OTHER |