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 | | 00400 | WEST VIRGINIA | 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 | 001837930 | OTHER | WEST VIRGINIA | MTN STATE SERVICE NUMBER |
| 2 | 734619 | OTHER | WEST VIRGINIA | NCPPO PROVIDER |
| 3 | 001837930 | OTHER | WEST VIRGINIA | MT ST BCBS SERVICE PROVIDER # |
| 4 | 3000318 | OTHER | WEST VIRGINIA | BRICKSTREET WORKERS COMP |
| 5 | FQ400 | OTHER | WEST VIRGINIA | HEALTH PLAN PROVIDER NO. |
| 6 | 001804181 | OTHER | WEST VIRGINIA | MTN STATE BC/BS PAY TO 1 |
| 7 | 1023337 | OTHER | WEST VIRGINIA | NCCPA |
| 8 | P00328118 | OTHER | WEST VIRGINIA | RAILROAD MEDICARE |
| 9 | 001967359 | OTHER | WEST VIRGINIA | MTN STATE BC/BS PAY TO 2 |
| 10 | 3810005145 | MEDICAID | WEST VIRGINIA | |
| 11 | 00400 | OTHER | WEST VIRGINIA | WVBOM PA-C LICENSE |
| 12 | WV400 | OTHER | WEST VIRGINIA | HEALTH PLAN |
