Provider Demographics
NPI:1104937945
Name:BLEVINS, MARYELLEN (PA)
Entity type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:
Last Name:BLEVINS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 WEST ST.
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:NY
Mailing Address - Zip Code:13619
Mailing Address - Country:US
Mailing Address - Phone:315-493-1000
Mailing Address - Fax:
Practice Address - Street 1:3 BRIDGE ST.
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:NY
Practice Address - Zip Code:13619
Practice Address - Country:US
Practice Address - Phone:315-493-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005666363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS67983Medicare UPIN