Provider Demographics
NPI:1932674413
Name:STARK, HANNAH (PA-C)
Entity Type:Individual
Prefix:
First Name:HANNAH
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 E MEDICAL TOWER DR
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-4872
Mailing Address - Country:US
Mailing Address - Phone:801-314-4266
Mailing Address - Fax:
Practice Address - Street 1:181 E MEDICAL TOWER DR
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-4872
Practice Address - Country:US
Practice Address - Phone:801-314-4266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT11446558-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program