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 | 2081P2900X | Physical Medicine & Rehabilitation | Pain Medicine | | | No |
| 2 | 363L00000X | Nurse Practitioner | | | | No |
| 3 | 363A00000X | Physician Assistant | | | | No |
| 4 | 332B00000X | Durable Medical Equipment & Medical Supplies | | | | No |
| 5 | 363AM0700X | Physician Assistant | Medical | | | No |
| 6 | 2081P2900X | Physical Medicine & Rehabilitation | Pain Medicine | | KENTUCKY | No |
| 7 | 208VP0014X | Pain Medicine | Interventional Pain Medicine | | KENTUCKY | No |
| 8 | 363LX0106X | Nurse Practitioner | Occupational Health | | | No |
| 9 | 363AS0400X | Physician Assistant | Surgical | | | No |
| 10 | 363LA2200X | Nurse Practitioner | Adult Health | | | No |
| 11 | 208VP0000X | Pain Medicine | Pain Medicine | | KENTUCKY | Yes |
| 12 | 291U00000X | Clinical Medical Laboratory | | | | No |
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 | 7100242090 | MEDICAID | KENTUCKY | |
| 2 | 64126766 | MEDICAID | KENTUCKY | |
| 3 | 7100239010 | MEDICAID | KENTUCKY | |
| 4 | 6371090001 | MEDICARE NSC | KENTUCKY | |
| 5 | 7100265660 | MEDICAID | KENTUCKY | |
| 6 | 7100240830 | MEDICAID | KENTUCKY | |
| 7 | 7100240700 | MEDICAID | KENTUCKY | |
| 8 | C23662 | MEDICARE UPIN | KENTUCKY | |
| 9 | 9968 | MEDICARE PIN | KENTUCKY | |
| 10 | 7100033310 | MEDICAID | KENTUCKY | |