Basic Information
| Provider Information | |||||||||
| NPI: | 1801078654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STARK | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15645 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891145645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028778600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 888 S RANCHO DR | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891063810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028778600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2007 | ||||||||
| LastUpdateDate: | 05/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5123 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA1068 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 5123 | 01 | AZ | AZ PA LICENSE | OTHER | PA1068 | 01 | NV | NV STATE LICENSE | OTHER | V114606 | 01 | NV | SMA MEDICARE | OTHER | MS2423767 | 01 | AZ | DEA | OTHER |