| NPI | 1508288531 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MELISSA REESE Provider Enrollment Officer 855-687-0618 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207R00000X Internal Medicine |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363L00000X Nurse Practitioner | |
| Enumeration Date | 2014-01-10 |
| Last Update Date | 2023-11-14 |