Provider Demographics
NPI:1255777561
Name:BLEDSOE, TREVOR
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:
Last Name:BLEDSOE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6601 WINCHESTER AVE STE 230
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64133-4681
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6601 WINCHESTER AVE STE 230
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64133
Practice Address - Country:US
Practice Address - Phone:816-313-2677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-14
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT545082085R0203X
390200000X
MO20180105852085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic RadiologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty