Provider Demographics
NPI:1669436820
Name:STARK, JACK MARSHALL (PA-C)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:MARSHALL
Last Name:STARK
Suffix:
Gender:M
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 1:100 RESERVE RD STE A4
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-5267
Mailing Address - Country:US
Mailing Address - Phone:203-794-1979
Mailing Address - Fax:203-794-1796
Practice Address - Street 1:100 RESERVE RD STE A4
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-5267
Practice Address - Country:US
Practice Address - Phone:203-794-1979
Practice Address - Fax:203-794-1796
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000044363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTS59703Medicare UPIN
CT970001356Medicare ID - Type Unspecified