| NPI | 1508419961 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JOHN DISTEFANO Business Manager 523-173-2143 |
| Organization Subpart ? | No |
| Primary Taxonomy | 208D00000X General Practice |
| Additional Taxonomies | 207N00000X Dermatology |
| 363LA2200X Nurse Practitioner, Adult Health | |
| 363LF0000X Nurse Practitioner, Family | |
| Enumeration Date | 2019-07-24 |
| Last Update Date | 2024-08-21 |