Individual
ETHAN SHANE BLEVINS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
381 4TH AVE, BETHEL, AK 99559
(907) 543-2242
Mailing address
PO BOX 528, ATTN: BH BAUTISTA, BETHEL, AK 99559
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1020986
—
AR
Enumeration date
06/14/2017
Last updated
06/14/2017
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