Healthcare Provider Details

I. General information

NPI: 1477245595
Provider Name (Legal Business Name): VICTORIA STARK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VICTORIA FERGUSON PA-C

II. Dates (important events)

Enumeration Date: 05/25/2023
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 N GRAND AVE
FORT THOMAS KY
41075-4027
US

IV. Provider business mailing address

PO BOX 638685
CINCINNATI OH
45263-8685
US

V. Phone/Fax

Practice location:
  • Phone: 859-572-3618
  • Fax: 859-572-2326
Mailing address:
  • Phone: 859-572-3617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3359
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: