Provider Demographics
NPI:1962628578
Name:STARK, JOHN MITCHELL (PTA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MITCHELL
Last Name:STARK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 HOMEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-2310
Mailing Address - Country:US
Mailing Address - Phone:901-647-5236
Mailing Address - Fax:
Practice Address - Street 1:2100 EXETER RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3922
Practice Address - Country:US
Practice Address - Phone:901-757-1350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPTA0000002893225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant