Provider Demographics
NPI:1801078654
Name:STARK, BRIAN WILLIAM JR (PA-C)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:WILLIAM
Last Name:STARK
Suffix:JR
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:PO BOX 100744
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3196 S MARYLAND PKWY STE 425
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2318
Practice Address - Country:US
Practice Address - Phone:725-205-0725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5123363A00000X
NVPA1068363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVPA1068OtherNV STATE LICENSE
NVV114606OtherSMA MEDICARE
NVV114606OtherSMA MEDICARE
AZMS2423767OtherDEA
NVPA1068OtherNV STATE LICENSE