Basic Information
| Provider Information | |||||||||
| NPI: | 1649334475 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPARKS | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9500 E IRONWOOD SQUARE DR STE 125 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852584582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806262552 | ||||||||
| FaxNumber: | 4806262551 | ||||||||
| Practice Location | |||||||||
| Address1: | 20045 N. 19TH AVENUE | ||||||||
| Address2: | BLDG 10, SUITE 3 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850273207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806262552 | ||||||||
| FaxNumber: | 4806262551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 13545 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 235326 | 05 | AZ | MEDICAID |