Provider Demographics
NPI:1396742284
Name:STARK, JACQUELINE (CRNA)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N TUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3807
Mailing Address - Country:US
Mailing Address - Phone:714-347-1010
Mailing Address - Fax:714-647-1245
Practice Address - Street 1:3350 W BALL RD
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-3710
Practice Address - Country:US
Practice Address - Phone:714-827-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR148323174400000X
CA3393367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD000831101Medicaid
MD000831101Medicaid
HIH102892Medicare PIN
GA43BBDDCMedicare PIN