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 | 207Q00000X | Family Medicine | | 05-19466 | KANSAS | No |
| 2 | 207Q00000X | Family Medicine | | R7C61 | MISSOURI | 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 | 080171268 | OTHER | KANSAS | RR MEDICARE |
| 2 | 18960020 | OTHER | | CFU BCBS |
| 3 | D16903 | MEDICARE UPIN | | |
| 4 | 157695XX | OTHER | | PREFERRED CARE OF NY |
| 5 | J615127A | MEDICARE PIN | KANSAS | |
| 6 | 10001637501 | OTHER | | CHP PIC HILLS |
| 7 | 326933 | OTHER | | FIRSTGUARD KUMW UC |
| 8 | 22039026 | OTHER | | BCBS PIC HILLS UC |
| 9 | 3732650 | OTHER | | AETNA KUMW UC |
| 10 | 2057247 | OTHER | | AETNA CFC |
| 11 | 25562039 | OTHER | | BCBS KUMW UC |
| 12 | 100391550A | MEDICAID | KANSAS | |
| 13 | 10001637500 | OTHER | | CHP CFC |
| 14 | 481159444 | OTHER | | JAYHAWK TAX ID |
| 15 | 39415017 | OTHER | | WW URGENT CARE |
| 16 | 11207011 | OTHER | | BCBS CFC |
| 17 | 1186358 | OTHER | | AETNA PICS HILLS UC |
| 18 | J615127 | MEDICARE PIN | MISSOURI | |
