Provider Demographics
NPI:1497955397
Name:STARK-VAN NOORD, KIMBERLY JEAN (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JEAN
Last Name:STARK-VAN NOORD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44021 DEQUINDRE
Mailing Address - Street 2:ATTN JAN MCFARLANE
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085
Mailing Address - Country:US
Mailing Address - Phone:248-964-8787
Mailing Address - Fax:248-964-6133
Practice Address - Street 1:44021 DEQUINDRE
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48085
Practice Address - Country:US
Practice Address - Phone:248-964-8787
Practice Address - Fax:248-964-6133
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004641363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F31794OtherBLUE CROSS BLUE SHIELD OF
MI383601519OtherCOMMERCIAL INSURANCE
MI0F31794OtherBLUE CROSS BLUE SHIELD OF