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 | 207Q00000X | Family Medicine | | 38151 | NORTH 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 | 0138R | OTHER | NORTH CAROLINA | BLUECROSS GROUP ID |
| 2 | 28472 | OTHER | NORTH CAROLINA | MAMSI ID |
| 3 | 8962644 | MEDICAID | NORTH CAROLINA | |
| 4 | 01-41632 | OTHER | NORTH CAROLINA | UNITED HEALTHCARE |
| 5 | 202595 | OTHER | NORTH CAROLINA | BLACK LUNG ID |
| 6 | 62644 | OTHER | NORTH CAROLINA | BCBS PERSONAL ID |
| 7 | 1942382940 | MEDICAID | NORTH CAROLINA | |
| 8 | 38151 | OTHER | NORTH CAROLINA | STATE LICENSE |
| 9 | 561794820 | OTHER | NORTH CAROLINA | PRUDENTIAL ID |
| 10 | 890138R | MEDICAID | NORTH CAROLINA | |
| 11 | 3926 | OTHER | NORTH CAROLINA | PARTNERS ID |
| 12 | 2723 | OTHER | NORTH CAROLINA | HEALTHSOURCE |
| 13 | 561794820 | OTHER | NORTH CAROLINA | AETNA US HEALTHCARE |
| 14 | 561794820 | OTHER | NORTH CAROLINA | CIGNA ID # |
