National Provider Identifier (NPI) Registration Form

National Provider Identifier (NPI) Registration Form
Register your provider details to apply for a National Provider Identifier. Please complete all fields accurately. Sensitive personal or financial information is not collected.
Provider Full Name
First NameLast Name
Organization or Practice Name
Practice Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Contact Email Address
example@example.com
Provider Type / Taxonomy
State License Number (if applicable)
Primary State of Practice
Brief Description of Services or Specialties
Should be Empty: