Healthcare Provider Details

I. General information

NPI: 1851877823
Provider Name (Legal Business Name): DEVIN STARK FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 N BRYAN AVE
LAMESA TX
79331-2451
US

IV. Provider business mailing address

4210 126TH ST
LUBBOCK TX
79423-1990
US

V. Phone/Fax

Practice location:
  • Phone: 806-872-2183
  • Fax:
Mailing address:
  • Phone: 214-460-8763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP138017
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: