Healthcare Provider Details

I. General information

NPI: 1174700934
Provider Name (Legal Business Name): MATTHEW T STARK PA-C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2008
Last Update Date: 06/11/2020
Certification Date: 06/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1937 W HARVARD AVE
ROSEBURG OR
97471-2720
US

IV. Provider business mailing address

2570 NW EDENBOWER BLVD STE 100
ROSEBURG OR
97471-6214
US

V. Phone/Fax

Practice location:
  • Phone: 541-677-7200
  • Fax: 541-229-3309
Mailing address:
  • Phone: 541-677-7200
  • Fax: 541-229-3309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: