Provider Demographics
NPI:1366573578
Name:STARK, LINDA DIANE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:DIANE
Last Name:STARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3923 FEDERAL HILL RD
Mailing Address - Street 2:
Mailing Address - City:JARRETTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21084-1525
Mailing Address - Country:US
Mailing Address - Phone:410-557-6663
Mailing Address - Fax:
Practice Address - Street 1:9105 FRANKLIN SQUARE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:ROSEDALE
Practice Address - State:MD
Practice Address - Zip Code:21237-3930
Practice Address - Country:US
Practice Address - Phone:443-777-8822
Practice Address - Fax:443-777-8823
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001036363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant