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 | 363AM0700X | Physician Assistant | Medical | 104212 | NORTH CAROLINA | No |
| 2 | 363A00000X | Physician Assistant | | 104212 | 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 | FH4001595 | OTHER | NORTH CAROLINA | FIRST CAROLINA CARE |
| 2 | 3211349 | OTHER | NORTH CAROLINA | UNITED HEALTHCARE |
| 3 | 1281161 | OTHER | NORTH CAROLINA | WELLPATH |
| 4 | 13268728 | OTHER | NORTH CAROLINA | PHCS/MULTIPLAN |
| 5 | 15235 | OTHER | NORTH CAROLINA | BCBS OF NC |
| 6 | 243133 | OTHER | NORTH CAROLINA | MEDCOST LLC |
| 7 | 6602644 | OTHER | NORTH CAROLINA | CIGNA GREATWEST |
| 8 | 1417135401 | MEDICAID | NORTH CAROLINA | |
| 9 | 1417135401 | OTHER | NORTH CAROLINA | HUMANA |
| 10 | 4015376 | OTHER | NORTH CAROLINA | COVENTRY NATIONAL - COVENTRY PPO |
| 11 | 1417135401 | OTHER | NORTH CAROLINA | DOCTORS DIRECT |
| 12 | 1417135401 | OTHER | NORTH CAROLINA | HEALTHSMART |
| 13 | 1417135401 | OTHER | NORTH CAROLINA | HEALTHNET FEDERAL SERVICES |
| 14 | 1281161 | OTHER | NORTH CAROLINA | COVENTRY OF THE CAROLINAS |
| 15 | 9928411 | OTHER | NORTH CAROLINA | AETNA |
