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 | 174400000X | Specialist | | 0101023599 | 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 | 2020511-S | OTHER | VIRGINIA | CIGNA |
| 2 | D-43711253 | OTHER | VIRGINIA | CHAMPUS TRICARE |
| 3 | 6861954 | OTHER | VIRGINIA | MEDICAID VA HMO |
| 4 | 27140 | OTHER | VIRGINIA | ALLIANCE PPO |
| 5 | 4054650 | OTHER | VIRGINIA | AETNA US HEALTHCARE PPO |
| 6 | C-62323 | MEDICARE UPIN | VIRGINIA | |
| 7 | 001961 AND 454203 | OTHER | VIRGINIA | ANTHEM BCBS OF VA |
| 8 | 250000292 C08088 | OTHER | VIRGINIA | MEDICARE VA |
| 9 | KI175785 | MEDICARE ID-TYPE UNSPECIFIED | VIRGINIA | |
| 10 | 0787066 | OTHER | VIRGINIA | AETNA HMO |
| 11 | 4371 0001 | OTHER | VIRGINIA | CAREFIRST BCBS |
| 12 | 6861954 | MEDICAID | VIRGINIA | |
| 13 | 22463 | OTHER | VIRGINIA | UNICARE |
| 14 | 001961 AND 454203 | OTHER | VIRGINIA | TRIGON VA |
