Provider Demographics
NPI:1144221094
Name:STORK, PAULA (CRNA)
Entity Type:Individual
Prefix:MS
First Name:PAULA
Middle Name:
Last Name:STORK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:PAULA
Other - Middle Name:
Other - Last Name:ENNEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 434
Mailing Address - Street 2:
Mailing Address - City:GASSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72635-0434
Mailing Address - Country:US
Mailing Address - Phone:870-435-4477
Mailing Address - Fax:
Practice Address - Street 1:160 HIGHWAY 201 N
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-3158
Practice Address - Country:US
Practice Address - Phone:870-508-2100
Practice Address - Fax:870-508-2150
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC00177367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR430024522OtherRAILROAD MEDICARE
AR59498OtherBLUE CROSS BLUE SHIELD AR
AR119778701Medicaid
AR430024522OtherRAILROAD MEDICARE