Basic Information
| Provider Information | |||||||||
| NPI: | 1811373988 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACQUELINE STARK NURSING PC | ||||||||
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| OtherOrganizationName: | BRONZE STAR MEDICAL STAFF SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 HOLLAND | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926182566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495882190 | ||||||||
| FaxNumber: | 9495882190 | ||||||||
| Practice Location | |||||||||
| Address1: | 2951 BLUEBELL AVE | ||||||||
| Address2: | |||||||||
| City: | BREA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928214702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146404460 | ||||||||
| FaxNumber: | 8886070923 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2015 | ||||||||
| LastUpdateDate: | 07/30/2015 | ||||||||
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| AuthorizedOfficialLastName: | STARK | ||||||||
| AuthorizedOfficialFirstName: | JACQUELINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7146404460 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.