Provider Demographics
NPI:1356851893
Name:ERVIN, RAY A (CNP)
Entity Type:Individual
Prefix:
First Name:RAY
Middle Name:A
Last Name:ERVIN
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 27TH ST STE B06
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2681
Mailing Address - Country:US
Mailing Address - Phone:740-356-6942
Mailing Address - Fax:740-356-7851
Practice Address - Street 1:246 COMMONWEALTH ROAD
Practice Address - Street 2:
Practice Address - City:VANCEBURG
Practice Address - State:KY
Practice Address - Zip Code:41179
Practice Address - Country:US
Practice Address - Phone:606-796-0010
Practice Address - Fax:606-796-0011
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH021924363L00000X
KY3011811363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0255888Medicaid
KY7100529910Medicaid