Provider Demographics
NPI:1750554895
Name:STARK, DANA (PA)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX N
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NE
Mailing Address - Zip Code:68446-0518
Mailing Address - Country:US
Mailing Address - Phone:402-269-2611
Mailing Address - Fax:
Practice Address - Street 1:2731 HEALTHCARE DR
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NE
Practice Address - Zip Code:68446-7880
Practice Address - Country:US
Practice Address - Phone:402-269-2611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0673363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6830390Medicaid
SDS102556Medicare PIN