Basic Information
Provider Information | |||||||||
NPI: | 1124443676 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STARK | ||||||||
FirstName: | SHANA | ||||||||
MiddleName: | S | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | N.P. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 67250 | ||||||||
Address2: |   | ||||||||
City: | LINCOLN | ||||||||
State: | NE | ||||||||
PostalCode: | 685067250 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4023288833 | ||||||||
FaxNumber: | 8889650959 | ||||||||
Practice Location | |||||||||
Address1: | 500 5TH ST | ||||||||
Address2: |   | ||||||||
City: | BROOKINGS | ||||||||
State: | OR | ||||||||
PostalCode: | 974159702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5414122000 | ||||||||
FaxNumber: | 5414122081 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/20/2014 | ||||||||
LastUpdateDate: | 09/16/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/16/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 201501818NP-PP | OR | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP2300X | 111628 | NE | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
ID | Type | State | Issuer | Description | 500684342 | 05 | OR |   | MEDICAID | 1487696985 | 01 | OR | CURRY HEALTH DISTRICT NPI | OTHER | 930937095 | 01 | OR | CURRY HEALTH DISTRICT TAX ID | OTHER |