| NPI | 1376973461 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | STEPHANIE PETERSON Manager Credentialing/Enrollment 877-564-3627 |
| Organization Subpart ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner |
| Additional Taxonomies | 2085R0202X Radiology, Diagnostic Radiology |
| 207R00000X Internal Medicine | |
| Enumeration Date | 2013-11-26 |
| Last Update Date | 2025-10-14 |