Provider Demographics
NPI:1255304176
Name:BLEVINS, ROGER OWEN (CPNP)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:OWEN
Last Name:BLEVINS
Suffix:
Gender:M
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MSC 10 5590
Mailing Address - Street 2:1 UNIVERSITY OF NEW MEXICO
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:602-644-0735
Mailing Address - Fax:
Practice Address - Street 1:MSC 10 5590
Practice Address - Street 2:1 UNIVERSITY OF NEW MEXICO
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:602-644-0735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0034727363LP0200X
AZAP4644363LP0200X
NMCNP02896363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q13287Medicare UPIN
OK242415400Medicare ID - Type Unspecified
OK100130790AMedicaid