Provider Demographics
NPI:1083036487
Name:STARK, KRISTA ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:ELIZABETH
Last Name:STARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 33369
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28233-3369
Mailing Address - Country:US
Mailing Address - Phone:704-364-8100
Mailing Address - Fax:704-365-2073
Practice Address - Street 1:10320 MALLARD CREEK RD STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-5204
Practice Address - Country:US
Practice Address - Phone:704-547-9196
Practice Address - Fax:704-547-8775
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-20
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04746363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1083036487Medicaid
NCNCH590BMedicare PIN
SC1844PAMedicaid