Provider Demographics
NPI:1457354904
Name:STARK, SANFORD R (CRNA, PHD)
Entity Type:Individual
Prefix:MR
First Name:SANFORD
Middle Name:R
Last Name:STARK
Suffix:
Gender:M
Credentials:CRNA, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 S GIRARD ST
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-5759
Mailing Address - Country:US
Mailing Address - Phone:856-853-9277
Mailing Address - Fax:856-853-1633
Practice Address - Street 1:323 S GIRARD ST
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-5759
Practice Address - Country:US
Practice Address - Phone:856-853-9277
Practice Address - Fax:856-853-1633
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR06803000367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ548377Medicare ID - Type Unspecified