MEDICARE: LISA PATRICE BLEVINS APRN-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	5003510	NC
2	363L00000X	Nurse Practitioner	144763	NC
3	363LF0000X	Family Nurse Practitioner	5003510	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1073707311	OTHER	NC	INDIVIDUAL TAX INDENTIFICATION

General Provider Information

NPI Number	:	1073707311
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA PATRICE BLEVINS APRN-BC

Provider Business Mailing Address
First Line	:	4705 UNIVERSITY DRIVE
Second Line	:	BLDG
City	:	DURHAM
State	:	NC
Zip	:	27707
Country	:	US
Telephone Number	:	919-237-1337
Fax Number	:	919-237-1625

Provider Business Practice Location Address
First Line	:	7850 BRIER CREEK PKWY STE 220
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27617-8900
Country	:	US
Telephone Number	:	919-578-7008
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2007
Last Update Date	:	07/14/2023

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