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 | | 1258 | SOUTH DAKOTA | 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 | 1258 | OTHER | SOUTH DAKOTA | DAKOTACARE |
| 2 | 659S6JA | OTHER | MINNESOTA | BCBS OF MN |
| 3 | AH908107523 | OTHER | SOUTH DAKOTA | PREFERRED ONE |
| 4 | D25374 | MEDICARE UPIN | SOUTH DAKOTA | |
| 5 | 5602007 | MEDICAID | SOUTH DAKOTA | |
| 6 | S102397 | MEDICARE PIN | SOUTH DAKOTA | |
| 7 | S40004 | MEDICARE PIN | SOUTH DAKOTA | |
| 8 | 12967 | OTHER | SOUTH DAKOTA | MIDLANDS CHOICE |
| 9 | 4995979 | OTHER | SOUTH DAKOTA | BCBS OF SOUTH DAKOTA |
| 10 | 659S 6JA | OTHER | MINNESOTA | CC SYSTEMS BLUE PLUS |
| 11 | 873765700 | MEDICAID | MINNESOTA | |
| 12 | 57028A004 | OTHER | SOUTH DAKOTA | WPS TRICARE |
| 13 | 68890 | OTHER | SOUTH DAKOTA | ARAZ/AMERICA'S PPO |
| 14 | 5602006 | MEDICAID | SOUTH DAKOTA | |
