Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 3049 | NC |
NPI | 1588686760 |
---|---|
Provider Name | Joshua Alexis Stevens |
First Address | Durham, NC 27707-3586 |
Second Address | Durham, NC 27707-3586 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0194L | BLUE CROSS/BLUE SHIELD (01) | NC |