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 | | 085002869 | ILLINOIS | No |
2 | 363A00000X | Physician Assistant | | PA05910 | TEXAS | 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 | 0739010002 | OTHER | ILLINOIS | MEDICARE NSC |
2 | 6484850003 | OTHER | TEXAS | MEDICARE NSC - EFFECT 02/01/2011 |
3 | 0739010003 | OTHER | ILLINOIS | MEDICARE NSC |
4 | 208592 | OTHER | ILLINOIS | MEDICARE LOCALITY 99 |
5 | 835N08 | OTHER | TEXAS | BC/BS TX - EFFECT 02/01/2011 |
6 | 8Y9532 | OTHER | TEXAS | BLUE CROSS BLUE SHIELD |
7 | P00477787 | OTHER | ILLINOIS | RAILROAD MEDICARE PTAN |
8 | 208887 | OTHER | ILLINOIS | MEDICARE LOCALITY 15 |
9 | P00935332 | OTHER | TEXAS | RAILROAD MEDICARE |
10 | 0739010008 | OTHER | ILLINOIS | MEDICARE NSC |
11 | 0739010006 | OTHER | ILLINOIS | MEDICARE NSC |
12 | CD4744 | OTHER | ILLINOIS | RAILROAD MEDICARE GROUP # |
13 | 0739010001 | OTHER | ILLINOIS | MEDICARE NSC |
14 | 0739010004 | OTHER | ILLINOIS | MEDICARE NSC |
15 | 0739010005 | OTHER | ILLINOIS | MEDICARE NSC |
16 | 0739010010 | OTHER | ILLINOIS | MEDICARE NSC |
17 | TXB128138 | OTHER | TEXAS | MEDICARE PART B - EFFECT. 05/03/2011 |
18 | 085002869 | OTHER | ILLINOIS | ST. OF IL LICENSE |
19 | 385001696 | OTHER | ILLINOIS | CONTROLLED SUBSTANCE |