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 | | PA-606 | IDAHO | 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 | 000010161379 | OTHER | IDAHO | REGENCE OF ID |
| 2 | 8H104 | OTHER | IDAHO | BLUE CROSS OF ID GROUP |
| 3 | 043634356 | OTHER | IDAHO | BRCHC TAX ID |
| 4 | 131828 | MEDICARE ID-TYPE UNSPECIFIED | IDAHO | FQHC MOBILE CLINIC |
| 5 | 1374276 | MEDICARE ID-TYPE UNSPECIFIED | IDAHO | PART B GROUP |
| 6 | 131832 | MEDICARE ID-TYPE UNSPECIFIED | IDAHO | FQHC SANDPOINT |
| 7 | PAF22 | OTHER | IDAHO | BLUE CROSS OF IDAHO |
| 8 | 000010142695 | OTHER | IDAHO | REGENCE OF ID GROUP |
| 9 | 131822 | MEDICARE ID-TYPE UNSPECIFIED | IDAHO | FQHC BONNERS FERRY |
| 10 | 8065901 | MEDICAID | IDAHO | |
| 11 | Q61323 | MEDICARE UPIN | IDAHO | |
