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 | 363LA2200X | Nurse Practitioner | Adult Health | | | No |
| 2 | 332B00000X | Durable Medical Equipment & Medical Supplies | | | | 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 | 0467F | OTHER | | BLUE CROSS BLUE SHIELD FEDERAL |
| 2 | 100347340A | MEDICAID | KANSAS | |
| 3 | 7586819301 | MEDICAID | KANSAS | |
| 4 | 7702534 | MEDICAID | NORTH CAROLINA | |
| 5 | 009107231 | MEDICAID | VIRGINIA | |
| 6 | 0467F | OTHER | NORTH CAROLINA | BLUE CROSS BLUE SHIELD OF NC |
| 7 | 263113 | OTHER | VIRGINIA | ANTHEM BLUE CROSS BLUE SH |
| 8 | 0467F | OTHER | | BLUE CROSS BLUE SHIELD FE |
| 9 | DM1152 | MEDICAID | SOUTH CAROLINA | |
| 10 | 0467F | OTHER | NORTH CAROLINA | BLUE CROSS BLUE SHIELD |
| 11 | 0467F | OTHER | NORTH CAROLINA | STATE OF NC TEACHERS AND |
| 12 | 263113 | OTHER | VIRGINIA | ANTHEM BLUE CROSS BLUE SHIELD OF VA |
| 13 | 0467F | OTHER | NORTH CAROLINA | STATE OF NC TEACHERS AND STATE EMPLOYEES |
