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 | 261QP2300X | Clinic/Center | Primary Care | | | No |
| 2 | 363LF0000X | Nurse Practitioner | Family | APN459 | SOUTH CAROLINA | No |
| 3 | 207Q00000X | Family Medicine | | 15157 | SOUTH CAROLINA | No |
| 4 | 207R00000X | Internal Medicine | | 15157 | SOUTH CAROLINA | No |
| 5 | 2080A0000X | Pediatrics | Adolescent Medicine | 15157 | SOUTH CAROLINA | No |
| 6 | 2083P0901X | Preventive Medicine | Public Health & General Preventive Medicine | 15157 | SOUTH CAROLINA | No |
| 7 | 2083X0100X | Preventive Medicine | Occupational Medicine | 15157 | SOUTH CAROLINA | No |
| 8 | 208D00000X | General Practice | | 15157 | SOUTH 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 | GP2905 | MEDICAID | SOUTH CAROLINA | |
| 2 | 7058 | MEDICARE PIN | SOUTH CAROLINA | |
| 3 | 7058 | MEDICARE ID-TYPE UNSPECIFIED | SOUTH CAROLINA | GROUP NUMBER |
