Provider Demographics
NPI:1013258201
Name:BLEVINS, STUART TRAVIS (NP)
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:TRAVIS
Last Name:BLEVINS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3095 KETTERING BLVD
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1983
Mailing Address - Country:US
Mailing Address - Phone:614-928-9400
Mailing Address - Fax:614-928-9401
Practice Address - Street 1:899 E BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-1156
Practice Address - Country:US
Practice Address - Phone:614-928-9400
Practice Address - Fax:614-928-9401
Is Sole Proprietor?:No
Enumeration Date:2013-03-13
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN280389-COA1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0094077Medicaid
20679468060OtherCARESOURCE
H245900Medicare PIN