Provider Demographics
NPI:1720545734
Name:STARK, JOSHUA DAVID (RN)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:DAVID
Last Name:STARK
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 W CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-2618
Mailing Address - Country:US
Mailing Address - Phone:480-233-1440
Mailing Address - Fax:
Practice Address - Street 1:350 W THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4496
Practice Address - Country:US
Practice Address - Phone:602-406-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR222068163WE0003X
AZTEMP232685363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WE0003XNursing Service ProvidersRegistered NurseEmergency