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 | | M-8828 | IDAHO | No |
| 2 | 207Q00000X | Family Medicine | | 35196 | SOUTH CAROLINA | No |
| 3 | 207Q00000X | Family Medicine | | 49480 | MINNESOTA | No |
| 4 | 207Q00000X | Family Medicine | | MD2019-0994 | NEW MEXICO | 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 | 0-569-979-8 | OTHER | IDAHO | ECFMG CERTIFICATION # |
| 2 | 00010145533 | OTHER | IDAHO | BLUESHIELD OF IDAHO GF # |
| 3 | 000010145534 | OTHER | IDAHO | BLUESHIELD OF IDAHO MH # |
| 4 | 000010145537 | OTHER | IDAHO | BLUESHIELD OF IDAHO GV # |
| 5 | 58826 | OTHER | IDAHO | BLUE CROSS OF IDAHO |
| 6 | 539004052 08 | OTHER | IDAHO | I-94 # CLASS H1B1 |
| 7 | 806780500 | MEDICAID | IDAHO | |
| 8 | 0007241559 | OTHER | IDAHO | AETNA ID # |
| 9 | 284867 | OTHER | IDAHO | ALTIUS HEALTH PLAN BILL # |
| 10 | CS10257 | OTHER | IDAHO | IDAHO CONTROLLED SUBST. # |
| 11 | M-8828 | OTHER | IDAHO | IDAHO MEDICAL LICENSE # |
| 12 | P00161243 | OTHER | IDAHO | RAILROAD MEDICARE BILL # |
