Provider Demographics
NPI:1972005601
Name:STARK, ANDIE MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDIE
Middle Name:MICHELLE
Last Name:STARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5300 ELLIOTT DRIVE
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-8632
Mailing Address - Country:US
Mailing Address - Phone:734-822-2826
Mailing Address - Fax:734-434-9517
Practice Address - Street 1:5300 ELLIOTT DRIVE
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-8632
Practice Address - Country:US
Practice Address - Phone:734-822-2826
Practice Address - Fax:734-434-9517
Is Sole Proprietor?:No
Enumeration Date:2018-03-08
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010018492255A2300X
MI5601010619363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer