TIMONTHY DONELL BLACK — NPI 1992396022 (Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Nurse Practitioner, Family in MOUNT AIRY, NC)

CMS-1500 Box 24J / 33a • NPI

1992396022

Type 1 Individual Rendering/Ordering

HIPAA NUCC Taxonomy • CMS Code

363LF0000X (CMS 50)

Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Nurse Practitioner, Family

Box 32 Service Location & ZIP+4

113 SCENIC OUTLET LN STE 2, MOUNT AIRY, NC, 27030-9978

✓ 9-Digit EDI 837 ZIP+4 (27030-9978)

Practice Phone & Referral Fax

(336) 352-4900

Fax: (336) 352-4901

✓ HHS OIG LEIE Sanction Screening — VERIFIED CLEAR: NPI 1992396022 (TIMONTHY DONELL BLACK) has 0 active federal exclusions across all 84,224 HHS OIG LEIE sanction records (Database Verified: 2026-11-11).

CMS Medicare Order & Referring PECOS Eligibility

This practitioner does not currently appear in the CMS individual Order & Referring PECOS file (may practice in pediatrics, commercial-only networks, or hospital-employed settings).

Official CMS NPPES Credential & Practice Profile

10-Digit NPI Number	`1992396022` (NPI-1 Individual Practitioner)
Provider / Legal Name	TIMONTHY DONELL BLACK
Plain-English Specialty	Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Nurse Practitioner, Family NUCC Code: `363LF0000X` (Nurse Practitioner, Family)
Certifying / Licensing Body	State Medical / Healthcare Licensing Board & National Specialty Board
Practice Location Address	113 SCENIC OUTLET LN STE 2, MOUNT AIRY, NC, 27030-9978
Practice Telephone / Fax	Tel: (336) 352-4900 \| Fax: (336) 352-4901
Administrative Mailing Address	1132 CARTER MOUNTAIN RD, STUART, VA, 24171-3769
Enumeration & Last Sync	Enumerated: 2021-02-01 \| CMS Record Updated: 2024-05-16

Clinic Location, Accessibility & Directions

📍 Practice Location & Patient Access

113 SCENIC OUTLET LN STE 2, MOUNT AIRY, NC, 27030-9978

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Plain-English Taxonomy & CMS Crosswalk (363LF0000X)

What Does Taxonomy Code 363LF0000X Mean?

In the HIPAA National Uniform Claim Committee (NUCC) classification, code 363LF0000X translates to:
"Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Nurse Practitioner, Family"

CMS-1500 Medicare Specialty Crosswalk: CMS Code 50 (Nurse Practitioner)
Certifying / Accrediting Authority: State Medical / Healthcare Licensing Board & National Specialty Board
Clinical Scope: Consult a verified Nurse Practitioner, Family for specialized diagnostic evaluation, treatment planning, and continuity of care.

Specialty Clinical Procedures & Therapeutic Classes

Standard Scope of Care (TIMONTHY DONELL BLACK)

Typical CPT / Diagnostic Procedures:

Comprehensive Outpatient & Inpatient Clinical Evaluation (CPT 99202–99215)
Diagnostic Workup, Laboratory Ordering & Evidence-Based Care Coordination
Preventive Screening, Patient Counseling & Multidisciplinary Referral

Common Therapeutic Classes:

Evidence-Based Specialty Pharmacotherapy & Preventive Regimens (CMS Part D Standard)

All Registered NUCC Taxonomies & State Licenses

Taxonomy Code & Plain-English Description	State License & Primary Status
`390200000X` — Student in an Organized Health Care Education/Training Program Plain English: Licensed & Credentialed Student in an Organized Health Care Education/Training Program	State: N/A \| License: `Verified` \| Primary: Secondary
`363LF0000X` — Nurse Practitioner, Family Plain English: Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Nurse Practitioner, Family	State: NC \| License: `5014067` \| Primary: Yes (Primary)

Medical Billing, RCM & Hospital Credentialing Teams:

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TIMONTHY DONELL BLACK (NPI #1992396022)