Provider Demographics
NPI:1063516110
Name:STASKA, MITCHELL CHARLES (MPA-C)
Entity type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:CHARLES
Last Name:STASKA
Suffix:
Gender:M
Credentials:MPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4551
Mailing Address - Country:US
Mailing Address - Phone:215-823-5800
Mailing Address - Fax:
Practice Address - Street 1:PHILADELPIA VETERANS HOSPITAL
Practice Address - Street 2:UNIVERSITY AND WOODLAND AVENUE
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-823-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA-000830-L363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA066219Medicare UPIN