MEDICARE: SAMANTHA STARK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1790498269
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA STARK

Provider Business Mailing Address
First Line	:	3308 SE 89TH ST TRLR 448
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73135-6237
Country	:	US
Telephone Number	:	405-861-9982
Fax Number	:

Provider Business Practice Location Address
First Line	:	3308 SE 89TH ST TRLR 448
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73135-6237
Country	:	US
Telephone Number	:	405-861-9982
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/29/2022
Last Update Date	:	12/29/2022

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Directions to “ SAMANTHA STARK ” Practice Location

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