Provider Demographics
NPI:1124443676
Name:STARK, SHANA S (NP)
Entity type:Individual
Prefix:MRS
First Name:SHANA
Middle Name:S
Last Name:STARK
Suffix:
Gender:F
Credentials:NP
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 67250
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-7250
Mailing Address - Country:US
Mailing Address - Phone:402-328-8833
Mailing Address - Fax:888-965-0959
Practice Address - Street 1:500 5TH ST
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-9702
Practice Address - Country:US
Practice Address - Phone:541-412-2000
Practice Address - Fax:541-412-2081
Is Sole Proprietor?:No
Enumeration Date:2014-02-20
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201501818NP-PP363LF0000X
NE111628363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500684342Medicaid
OR1487696985OtherCURRY HEALTH DISTRICT NPI
OR930937095OtherCURRY HEALTH DISTRICT TAX ID
OR930937095OtherCURRY HEALTH DISTRICT TAX ID