Provider Demographics
NPI:1831747955
Name:SPROLES, BLAKLEY WALKER (PA-C)
Entity type:Individual
Prefix:MR
First Name:BLAKLEY
Middle Name:WALKER
Last Name:SPROLES
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 S GREAT SOUTHWEST PKWY APT 307
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-7385
Mailing Address - Country:US
Mailing Address - Phone:276-791-0837
Mailing Address - Fax:
Practice Address - Street 1:2410 ATHERHOLT RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2148
Practice Address - Country:US
Practice Address - Phone:434-200-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-02
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA17104363A00000X
VA0110-007454363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant