Provider Demographics
NPI:1194047282
Name:STARK INDUSTRIES MEDICAL
Entity type:Organization
Organization Name:STARK INDUSTRIES MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:STARK
Authorized Official - Suffix:JR
Authorized Official - Credentials:PA-C
Authorized Official - Phone:702-250-9022
Mailing Address - Street 1:6647 BROOKLYN HEIGHTS ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89166-8020
Mailing Address - Country:US
Mailing Address - Phone:702-250-9022
Mailing Address - Fax:702-685-6896
Practice Address - Street 1:6647 BROOKLYN HEIGHTS ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89166-8020
Practice Address - Country:US
Practice Address - Phone:702-250-9022
Practice Address - Fax:702-685-6896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1068363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty