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NPI Code Detail

MEDICARE: STARK INDUSTRIES MEDICAL

MEDICARE: STARK INDUSTRIES MEDICAL
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363AM0700XMedical Physician AssistantPA1068NV
2363AS0400XSurgical Physician AssistantPA1068NV

General Provider Information

NPI Number : 1194047282
Entity Type Code : Organization
Provider Name (Legal Business Name) : STARK INDUSTRIES MEDICAL
Provider Business Mailing Address
First Line : 6647 BROOKLYN HEIGHTS ST
Second Line :
City : LAS VEGAS
State : NV
Zip : 89166-8020
Country : US
Telephone Number : 702-250-9022
Fax Number : 702-685-6896
Provider Business Practice Location Address
First Line : 6647 BROOKLYN HEIGHTS ST
Second Line :
City : LAS VEGAS
State : NV
Zip : 89166-8020
Country : US
Telephone Number : 702-250-9022
Fax Number : 702-685-6896
Authorized Official
Title or Position : PRESIDENT
Name : BRIAN WILLIAM STARK JR.
Credential : PA-C
Telephone Number : 702-250-9022
Provider Enumeration Date : 02/17/2010
Last Update Date : 02/17/2010

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Directions to “STARK INDUSTRIES MEDICAL ” Practice Location

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