Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 20A6829 | CA |
Y | 207QA0401X | Family Doctor - Addiction Medicine | OP61153857 | WA |
NPI | 1548309651 |
---|---|
Provider Name | Neil Brandan Stark |
First Address | Bellingham, WA 98226-6614 |
Second Address | Bellingham, WA 98226-6614 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/02/2007 |
Last Update Date | 13/08/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G47503 | (02) | CA |