Provider Demographics
NPI:1790705218
Name:BLEVINS, BRANDI L (PA)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:L
Last Name:BLEVINS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 CATON AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-5201
Mailing Address - Country:US
Mailing Address - Phone:410-368-8640
Mailing Address - Fax:410-368-8644
Practice Address - Street 1:900 CATON AVENUE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229
Practice Address - Country:US
Practice Address - Phone:410-368-2414
Practice Address - Fax:410-951-4007
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003284363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q68606Medicare UPIN
MDK519N829Medicare ID - Type Unspecified