Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 45095 | KY |
Y | 2080P0204X | Pediatric Emergency Doctor | 45095 | KY |
N | 2080P0204X | Pediatric Emergency Doctor | ME123631 | FL |
NPI | 1215246202 |
---|---|
Provider Name | Dr. Wayne Nelson Stark JR. |
First Address | Chicago, IL 60677-6351 |
Second Address | Louisville, KY 40207-4714 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/09/2010 |
Last Update Date | 29/04/2021 |