| NPI | 1508419961 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JOHN DISTEFANO Business Manager 523-173-2143 |
| Organization Subpart ? | No |
| Primary Taxonomy | 208D00000X General Practice |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health |
| 207N00000X Dermatology | |
| 363LA2200X Nurse Practitioner, Adult Health | |
| 2084P0800X Psychiatry & Neurology, Psychiatry | |
| 261QH0100X Clinic/Center, Health Services | |
| 363LF0000X Nurse Practitioner, Family | |
| Enumeration Date | 2019-07-24 |
| Last Update Date | 2025-10-21 |