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 | | | | No |
| 2 | 363AM0700X | Physician Assistant | Medical | PA9102896 | FLORIDA | No |
| 3 | 363AM0700X | Physician Assistant | Medical | PA56715 | CALIFORNIA | No |
| 4 | 363A00000X | Physician Assistant | | 006718 | GEORGIA | 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 | 085.002169 | OTHER | ILLINOIS | DEPT OF FINANCIAL AND PROFESSIONAL REGULATION |
| 2 | 385.005610 | OTHER | ILLINOIS | ILLINOIS CONTROLLED SUBSTANCE LICENSE |
| 3 | 002087 | OTHER | IOWA | IOWA DEPT OF PUBLIC HEALTH MEDICAL LICENSE |
| 4 | 292421800 | MEDICAID | FLORIDA | |
| 5 | 9874 | OTHER | MINNESOTA | MINNESOTA BOARD OF MEDICAL PRACTICE PHYSICIAN ASST LICENSURE (EXP 06-30-2005) |
| 6 | 00005751 | OTHER | FLORIDA | FLORIDA PRESCRIBING QUALIFICATION |
| 7 | AMD-919 | OTHER | HAWAII | DEPT OF COMMERCE AND CONSUMER AFFAIRS |
| 8 | UNKNOWN | OTHER | IOWA | MAGELLAN OF IOWA - BROADLAWNS MEDICAL CENTER |
| 9 | 023740-01 | OTHER | NEW YORK | DIVISION OF PROFESSIONAL LICENSING SERVICES |
| 10 | PA56715 | OTHER | CALIFORNIA | DEPT OF CONSUMER AFFAIRS - PHY ASST LICENSE |
| 11 | 1060096 | OTHER | | NATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS |
| 12 | 1721-023 | OTHER | WISCONSIN | WISCONSIN DEPT OF REGULATION AND LICENSING |
| 13 | 6718 | OTHER | GEORGIA | PHYSICIAN ASSISTANT |
| 14 | U8969Z | OTHER | FLORIDA | MEDICARE |
| 15 | 5101395 | OTHER | IOWA | IOWA CONTROLLED SUBSTANCE ACT LICENSE (EXPIRED) |
| 16 | 9102896 | OTHER | FLORIDA | FLORIDA DEPT OF HEALTH PHYSICIAN ASST LICENSURE |
