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 | 207R00000X | Internal Medicine | | 4742 | NORTH DAKOTA | 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 | 4999829 | OTHER | | WELLMARCK OF SD |
| 2 | 123993 | OTHER | NORTH DAKOTA | WORKER'S COMP |
| 3 | 14678 | MEDICAID | NORTH DAKOTA | |
| 4 | 94433 | OTHER | | BLUE CROSS OTHER |
| 5 | 3018140 | MEDICAID | WASHINGTON | |
| 6 | 10773 | OTHER | NORTH CAROLINA | ND BC/BS |
| 7 | 10773 | MEDICARE ID-TYPE UNSPECIFIED | NORTH DAKOTA | |
| 8 | 7776130 | MEDICAID | SOUTH DAKOTA | |
| 9 | 30786 | OTHER | | SIOUX VALLEY |
| 10 | D28608 | MEDICARE UPIN | | |
| 11 | 45034068812 | MEDICAID | NEBRASKA | |
