Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 07405 | MS |
Y | 208600000X | Surgeon | 07405 | MS |
N | 2082S0105X | Plastic Hand Surgeon | 07405 | MS |
NPI | 1619907045 |
---|---|
Provider Name | Phillip Blevins |
First Address | Jackson, MS 39225-4146 |
Second Address | Jackson, MS 39216-4500 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/07/2006 |
Last Update Date | 13/06/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00012332 | (05) | MS |
512I240019 | (02) | |
D62906 | (02) | MS |