Basic Information
| Provider Information | |||||||||
| NPI: | 1013258201 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLEVINS | ||||||||
| FirstName: | STUART | ||||||||
| MiddleName: | TRAVIS | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3095 KETTERING BLVD | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6149289400 | ||||||||
| FaxNumber: | 6149289401 | ||||||||
| Practice Location | |||||||||
| Address1: | 899 E BROAD ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432051156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6149289400 | ||||||||
| FaxNumber: | 6149289401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2013 | ||||||||
| LastUpdateDate: | 05/25/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | RN280389-COA1 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0094077 | 05 | OH | MEDICAID | 20679468060 | 01 | CARESOURCE | OTHER |