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 | 363L00000X | Nurse Practitioner | | | | No |
| 2 | 207T00000X | Neurological Surgery | | | | No |
| 3 | 2084P0800X | Psychiatry & Neurology | Psychiatry | | | No |
| 4 | 2085N0700X | Radiology | Neuroradiology | | | No |
| 5 | 332B00000X | Durable Medical Equipment & Medical Supplies | | | | No |
| 6 | 208VP0014X | Pain Medicine | Interventional Pain Medicine | | KENTUCKY | No |
| 7 | 2081P2900X | Physical Medicine & Rehabilitation | Pain Medicine | | KENTUCKY | No |
| 8 | 332BC3200X | Durable Medical Equipment & Medical Supplies | Customized Equipment | | | No |
| 9 | 332BN1400X | Durable Medical Equipment & Medical Supplies | Nursing Facility Supplies | | | No |
| 10 | 363LA2200X | Nurse Practitioner | Adult Health | | | No |
| 11 | 363LX0106X | Nurse Practitioner | Occupational Health | | | No |
| 12 | 363AM0700X | Physician Assistant | Medical | | | No |
| 13 | 363AS0400X | Physician Assistant | Surgical | | | No |
| 14 | 363A00000X | Physician Assistant | | | | No |
| 15 | 208VP0000X | Pain Medicine | Pain Medicine | | | 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 | 65926552 | MEDICAID | KENTUCKY | |
| 2 | CD2933 | OTHER | KENTUCKY | RAILROAD MCARE |
| 3 | 3810003494 | OTHER | KENTUCKY | WV MEDICAID |
| 4 | 7100241280 | MEDICAID | KENTUCKY | |
| 5 | 90102344 | MEDICAID | KENTUCKY | |
| 6 | 7100241170 | MEDICAID | KENTUCKY | |
| 7 | 7100246380 | MEDICAID | KENTUCKY | |
| 8 | 1026130001 | MEDICARE NSC | KENTUCKY | |
| 9 | 2472800 | OTHER | KENTUCKY | OHIO MEDICAID |
| 10 | 7100241790 | MEDICAID | KENTUCKY | |
| 11 | 3165 | MEDICARE PIN | KENTUCKY | |
| 12 | 7100243230 | MEDICAID | KENTUCKY | |
| 13 | 7100244620 | MEDICAID | KENTUCKY | |
