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 | 363A00000X | Physician Assistant | | PA 00254 | RHODE ISLAND | No |
| 2 | 363A00000X | Physician Assistant | | 1281 | MASSACHUSETTS | No |
| 3 | 363A00000X | Physician Assistant | | 5181 | SOUTH CAROLINA | 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 | 24192 | OTHER | RHODE ISLAND | CONTROLLED SUBSTANCE |
| 2 | MC0437550J | OTHER | MASSACHUSETTS | CONTROLLED SUBSTANCE |
| 3 | 05 0501339 | OTHER | | HEALTHCARE VALUE MANAG |
| 4 | 12266RIH | OTHER | | HARVARD PILGRIM |
| 5 | 720118301 | OTHER | | CIGNA |
| 6 | 1156 | OTHER | | NEIGHBORHOOD HEALTH PLAN |
| 7 | 408400 | OTHER | | BLUE CHIP |
| 8 | 05 0501339 | OTHER | | SIERRA MILITARY |
| 9 | 1281 | OTHER | MASSACHUSETTS | LICENCE |
| 10 | PA00254 | OTHER | RHODE ISLAND | LICENCE |
| 11 | 23281 0 | OTHER | RHODE ISLAND | BLUE CROSS |
| 12 | 6807PA | MEDICAID | SOUTH CAROLINA | |
| 13 | 9023281 | OTHER | | EDS OF RI INDIV |
| 14 | NS34351 | OTHER | | EDS OF RI GROUP |
| 15 | 05 0501339 | OTHER | | TAX ID |
| 16 | SCS5777628 | OTHER | SOUTH CAROLINA | MEDICARE PIN |
