Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0105X | Surgery of the Hand | 22545 | WI |
NPI | 1780655928 |
---|---|
Provider Name | Ron H Stark |
First Address | Milwaukee, WI 53222-4305 |
Second Address | Milwaukee, WI 53222-4305 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/01/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
22545 | MEDICAL LICENSE (01) | WI |
30741000 | (05) | WI |
AS8894405 | DEA (01) | |
B56831 | (02) |