Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 363AM0700X | Physician Assistant | Medical | 311 | WYOMING | No |
| 2 | 363AM0700X | Physician Assistant | Medical | 337 | MONTANA | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 4308759 | OTHER | MONTANA | MDCD PIN |
| 2 | 000085503 | MEDICARE PIN | MONTANA | |
| 3 | 312270 | OTHER | WYOMING | BLUE CROSS CODY WY |
| 4 | 000083280 | MEDICARE ID-TYPE UNSPECIFIED | MONTANA | |
| 5 | 1153260006 | MEDICARE PIN | MONTANA | |
| 6 | 118763500 | MEDICARE ID-TYPE UNSPECIFIED | WYOMING | |
| 7 | 810511516011 | OTHER | MONTANA | EBMS |
| 8 | 000094963 | OTHER | MONTANA | BLUE CROSS BUTTE MT |
| 9 | 9762 | MEDICARE ID-TYPE UNSPECIFIED | WYOMING | RAILROAD MEDICARE |
| 10 | 000085504 | MEDICARE PIN | MONTANA | |
| 11 | 000097533 | OTHER | MONTANA | BCBS PIN |
| 12 | P88473 | MEDICARE UPIN | | |
| 13 | 4301357 | MEDICAID | MONTANA | |
| 14 | P00356151 | MEDICARE PIN | MONTANA | |
| 15 | 312239 | OTHER | WYOMING | BLUE CROSS SHERIDAN WY |
| 16 | W9762 | MEDICARE ID-TYPE UNSPECIFIED | WYOMING | |
| 17 | P00019117 | MEDICARE ID-TYPE UNSPECIFIED | MONTANA | RAILROAD MEDICARE |
| 18 | 000094953 | OTHER | MONTANA | BLUE CROSS BILLINGS MT |
