Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LA2100X | Nurse Practitioner - Acute Care | 250379 | WI |
NPI | 1023660974 |
---|---|
Provider Name | Tomas Karlton Grant SR. |
First Address | Milwaukee, WI 53226-3522 |
Second Address | Milwaukee, WI 53226-3522 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/07/2019 |
Last Update Date | 01/10/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1023660974 | (05) | WI |