| NPI | 1760985089 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | SHAD W. TILLOTSON CEO 385-455-3899 |
| Organization Subpart ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: UT 6223314-4405) |
| Enumeration Date | 2018-03-13 |
| Last Update Date | 2018-03-13 |