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 | 152W00000X | Optometrist | | 1726 | MINNESOTA | 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 | 2201181 | OTHER | MINNESOTA | MEDICA PRIMARY |
| 2 | 935300648002 | OTHER | MINNESOTA | PREFERRED ONE |
| 3 | HP28010 | OTHER | MINNESOTA | HEALTH PARTNERS |
| 4 | 410001616 | MEDICARE ID-TYPE UNSPECIFIED | MINNESOTA | |
| 5 | 101880 | OTHER | MINNESOTA | UCARE SRS AND MN |
| 6 | T39869 | MEDICARE UPIN | | |
| 7 | 10905 | OTHER | MINNESOTA | COLE MANAGED VISION |
| 8 | 2201179 | OTHER | MINNESOTA | SELECT CARE |
| 9 | 644S9HE | OTHER | MINNESOTA | BLUE CROSS/BLUE SHIELD |
| 10 | 410000102 | MEDICARE ID-TYPE UNSPECIFIED | MINNESOTA | |
| 11 | 2201179 | OTHER | MINNESOTA | MEDICA CHOICE |
| 12 | 23709 | OTHER | MINNESOTA | ARAZ/AMERICA'S PPO |
| 13 | 2205475 | OTHER | MINNESOTA | SELECT CARE |
| 14 | 410028968 | OTHER | MINNESOTA | MEDICA RAILROAD |
| 15 | 964110648002 | OTHER | MINNESOTA | PREFERRED ONE |
| 16 | 144823400 | MEDICAID | MINNESOTA | |
| 17 | 2205475 | OTHER | MINNESOTA | MEDICA CHOICE |
| 18 | 4C600HE | OTHER | MINNESOTA | BLUE CROSS/BLUE SHIELD |
