Provider Demographics
NPI:1851352884
Name:STARK, MARY JEAN (PAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JEAN
Last Name:STARK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-639-3350
Mailing Address - Fax:717-303-3546
Practice Address - Street 1:9 NATHAN LN
Practice Address - Street 2:
Practice Address - City:ANNVILLE
Practice Address - State:PA
Practice Address - Zip Code:17003-6500
Practice Address - Country:US
Practice Address - Phone:717-639-3350
Practice Address - Fax:717-303-3546
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003135L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA03246701OtherCAPITAL BLUE CROSS
P00791043OtherRAILROAD MEDICARE
PA110501FEUMedicare PIN
PA120981KAGMedicare PIN
PA03246701OtherCAPITAL BLUE CROSS
P00791043OtherRAILROAD MEDICARE