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 | 207W00000X | Ophthalmology | | 2015030665 | MISSOURI | Yes |
| 2 | 207W00000X | Ophthalmology | | MD00026367 | WASHINGTON | No |
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 | 891451 | OTHER | WASHINGTON | CRIME VICTIMS GROUP # |
| 2 | EV8144 | OTHER | WASHINGTON | REGENCE GROUP NUMBER |
| 3 | 91162803298116A002 | OTHER | WASHINGTON | TRICARE/WPS BURIEN # |
| 4 | 9116JA | OTHER | WASHINGTON | REGENCE AUBURN RYDER # |
| 5 | 0870427 | OTHER | WASHINGTON | AETNA GROUP NUMBER |
| 6 | 59460 | OTHER | WASHINGTON | L&I GROUP NUMBER |
| 7 | 180017371 | OTHER | WASHINGTON | RAILROAD MEDICARE IND # |
| 8 | 91162803298003A002 | OTHER | WASHINGTON | TRICARE/WPS FED WAY # |
| 9 | 2147JA | OTHER | WASHINGTON | REGENCE BURIEN RYDER # |
| 10 | 59459 | OTHER | WASHINGTON | L&I INDIVIDUAL NUMBER |
| 11 | 911628032 | OTHER | WASHINGTON | BLUE CROSS PREMERA |
| 12 | 91162803298002A002 | OTHER | WASHINGTON | TRICARE & WPS AUBURN # |
| 13 | 8120586 | MEDICAID | WASHINGTON | |
| 14 | 8914516 | OTHER | WASHINGTON | CRIME VICTIMS INDIVIDUAL |
| 15 | JA8144 | OTHER | WASHINGTON | REGENCE FEDERAL WAY RYDER |
| 16 | 7080781 | MEDICAID | WASHINGTON | |
