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General NPI Number Information
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NPI Number | 1063754208
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Entity Type | Organization
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Legal Business Name | STARK MEDICAL GROUP PC
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Dates
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Enumeration Date | 03/26/2013
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Last Update Date | 10/19/2022
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Provider Practice Location Address
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Address Line | 932 W IDAHO AVE STE 100
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City | ONTARIO
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State | OR
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Zip | 97914-2155
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Country | US
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Telephone | 541-889-2244
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Fax | 541-889-2626
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Provider Business Mailing Address
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Address Line | PO BOX J
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City | ONTARIO
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State | OR
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Zip | 97914-0020
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Country | US
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Telephone | 541-889-2244
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Fax | 541-889-2626
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | BRENDA L STARK
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Credential |
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Telephone | 541-889-2244
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 200550081NP
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 079043254N1
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License Number State | OR
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