Basic Information
Provider Information | |||||||||
NPI: | 1730469180 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SPARROW | ||||||||
FirstName: | PATRICK | ||||||||
MiddleName: | REAGAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6350 W A J HWY | ||||||||
Address2: | DEPARTMENT 100 | ||||||||
City: | TALBOTT | ||||||||
State: | TN | ||||||||
PostalCode: | 378778605 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8003553565 | ||||||||
FaxNumber: | 4237142355 | ||||||||
Practice Location | |||||||||
Address1: | 4330 MAYNARDVILLE HWY | ||||||||
Address2: |   | ||||||||
City: | MAYNARDVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 378073618 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8659923849 | ||||||||
FaxNumber: | 8659925166 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/17/2011 | ||||||||
LastUpdateDate: | 08/17/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | Y |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
No ID Information.