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 | 363A00000X | Physician Assistant | | 5601005153 | MICHIGAN | 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 | 381908328-407 BAYSID | OTHER | MICHIGAN | CCM/CARE SOURCE |
| 2 | 1027818 DRG | OTHER | MICHIGAN | MCLAREN HEALTH PLAN |
| 3 | 164342 | OTHER | MICHIGAN | GREAT LAKES HEALTH PLAN |
| 4 | 381908328-380 DRG | OTHER | MICHIGAN | CCM/CARE SOURCE |
| 5 | 4686650 | OTHER | MICHIGAN | MOLINA HEALTHCARE |
| 6 | 381908328412 COMMER | OTHER | MICHIGAN | CCM/CARE SOURCE |
| 7 | 381908328413 ST.VIN | OTHER | MICHIGAN | CCM/CARE SOURCE |
| 8 | 381908328410RUFFIN | OTHER | MICHIGAN | CCM/CARE SOURCE |
| 9 | 1027818 DRG | OTHER | MICHIGAN | HEALTHADVANTAGE |
| 10 | 0G36111-068 | MEDICARE PIN | MICHIGAN | |
| 11 | 381908328411 OUTER | OTHER | MICHIGAN | CCM/CARE SOURCE |
| 12 | 381908328409 JANES | OTHER | MICHIGAN | CCM/CARE SOURCE |
| 13 | 381908328408BRIDGEPO | OTHER | MICHIGAN | CCM/CARESOURCE |