Basic Information
| Provider Information | |||||||||
| NPI: | 1013994953 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAKE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | VAYDEN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1112 | ||||||||
| Address2: | |||||||||
| City: | FAIRMONT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265551112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049861750 | ||||||||
| FaxNumber: | 3049863742 | ||||||||
| Practice Location | |||||||||
| Address1: | 118 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | MANNINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265821131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049861750 | ||||||||
| FaxNumber: | 3049863742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2005 | ||||||||
| LastUpdateDate: | 12/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 202 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 929 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.