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 | 208000000X | Pediatrics | | 1451 | WEST VIRGINIA | No |
| 2 | 208000000X | Pediatrics | | 15140 | WEST VIRGINIA | No |
| 3 | 208000000X | Pediatrics | | 18217 | WEST VIRGINIA | No |
| 4 | 208000000X | Pediatrics | | 16381 | WEST VIRGINIA | No |
| 5 | 291U00000X | Clinical Medical Laboratory | | 51D0910134 | WEST VIRGINIA | No |
| 6 | 363L00000X | Nurse Practitioner | | 18804 | WEST VIRGINIA | No |
| 7 | 208000000X | Pediatrics | | 731 | WEST VIRGINIA | 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 | 1922061076 | OTHER | WEST VIRGINIA | SUE ANN UPTON,MD NPI # |
| 2 | 1598744757 | OTHER | WEST VIRGINIA | NPI # PENNY DIVITA,DO |
| 3 | 0107822000 | MEDICAID | WEST VIRGINIA | |
| 4 | 0112455000 | MEDICAID | WEST VIRGINIA | |
| 5 | 1013971761 | OTHER | WEST VIRGINIA | NPI# BRENDA WALKER,CFNP |
| 6 | 4000022000 | MEDICAID | WEST VIRGINIA | |
| 7 | 1295798361 | OTHER | WEST VIRGINIA | NPI # CAROL FRAIL, MD |
| 8 | F53257 | MEDICARE UPIN | WEST VIRGINIA | |
| 9 | 1003000000 | MEDICAID | WEST VIRGINIA | |
| 10 | G15685 | MEDICARE UPIN | WEST VIRGINIA | |
| 11 | 0105170000 | MEDICAID | WEST VIRGINIA | |
| 12 | 1912961343 | OTHER | WEST VIRGINIA | NPI # JOE MATUSIC, MD |
| 13 | F18699 | MEDICARE UPIN | WEST VIRGINIA | |
| 14 | 0792053 | MEDICARE ID-TYPE UNSPECIFIED | WEST VIRGINIA | MEDICARE # PENNY DIVITA |
| 15 | G42653 | MEDICARE UPIN | WEST VIRGINIA | |
| 16 | F53258 | MEDICARE UPIN | WEST VIRGINIA | |
| 17 | 0167011000 | MEDICAID | WEST VIRGINIA | |