Healthcare Provider Details

I. General information

NPI: 1750554895
Provider Name (Legal Business Name): DANA STARK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2731 HEALTHCARE DR
SYRACUSE NE
68446-7880
US

IV. Provider business mailing address

PO BOX N
SYRACUSE NE
68446-0518
US

V. Phone/Fax

Practice location:
  • Phone: 402-269-2611
  • Fax:
Mailing address:
  • Phone: 402-269-2611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0673
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: