Provider Demographics
NPI:1790876449
Name:STARK, PAUL HUNTER (PT)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:HUNTER
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 1:707 E CERVANTES ST STE B216
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-3286
Mailing Address - Country:US
Mailing Address - Phone:850-912-9203
Mailing Address - Fax:
Practice Address - Street 1:375 N 9TH AVE STE B
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32502-4905
Practice Address - Country:US
Practice Address - Phone:850-912-9203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT293314225100000X
FL26714225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP0036427OtherMEDICARE RR
MS09013483Medicaid
MS650000381STAMedicare PIN
MS09013483Medicaid