Healthcare Provider Details

I. General information

NPI: 1558320697
Provider Name (Legal Business Name): PATRICIA CALDWELL STARK RN ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2006
Last Update Date: 09/01/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 HEWITT DR
WACO TX
76712-8486
US

IV. Provider business mailing address

PO BOX 848476
DALLAS TX
75284-8476
US

V. Phone/Fax

Practice location:
  • Phone: 254-202-7800
  • Fax: 254-202-7856
Mailing address:
  • Phone: 254-202-4655
  • Fax: 254-202-4697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number445849
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP107316
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: