Provider Demographics
NPI:1093745093
Name:STARK, BRIAN ALAN (CRNA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:ALAN
Last Name:STARK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5604 FRIENDSHIP RD
Mailing Address - Street 2:
Mailing Address - City:HALETHORPE
Mailing Address - State:MD
Mailing Address - Zip Code:21227
Mailing Address - Country:US
Mailing Address - Phone:410-242-8728
Mailing Address - Fax:410-242-8728
Practice Address - Street 1:5604 FRIENDSHIP RD
Practice Address - Street 2:
Practice Address - City:HALETHORPE
Practice Address - State:MD
Practice Address - Zip Code:21227
Practice Address - Country:US
Practice Address - Phone:410-242-8728
Practice Address - Fax:410-242-8728
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR083302367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NA44Medicare ID - Type Unspecified