Healthcare Provider Details

I. General information

NPI: 1063754208
Provider Name (Legal Business Name): STARK MEDICAL GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2013
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

932 W IDAHO AVE STE 100
ONTARIO OR
97914-2155
US

IV. Provider business mailing address

PO BOX J
ONTARIO OR
97914-0020
US

V. Phone/Fax

Practice location:
  • Phone: 541-889-2244
  • Fax: 541-889-2626
Mailing address:
  • Phone: 541-889-2244
  • Fax: 541-889-2626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number079043254N1
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number200550081NP
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: BRENDA L STARK
Title or Position: OFFICE MANAGER
Credential:
Phone: 541-889-2244