Provider Demographics
NPI:1114904083
Name:STARK, DANE MICHAEL (PT)
Entity Type:Individual
Prefix:
First Name:DANE
Middle Name:MICHAEL
Last Name:STARK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1923 N WEBB RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3405
Mailing Address - Country:US
Mailing Address - Phone:316-262-4886
Mailing Address - Fax:316-262-4887
Practice Address - Street 1:1923 N WEBB RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3405
Practice Address - Country:US
Practice Address - Phone:316-262-4886
Practice Address - Fax:316-262-4887
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01968225100000X
KS1101792225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS140562Medicare ID - Type Unspecified
KSP99005Medicare UPIN