Basic Information
| Provider Information | |||||||||
| NPI: | 1629128483 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAIR | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1783 | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834031783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085528774 | ||||||||
| FaxNumber: | 2085232025 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 S WOODRUFF AVE STE 15B | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834046372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083574633 | ||||||||
| FaxNumber: | 2084190690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 03/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N21972 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | NP772A | 01 | ID | NURSE PRACTITIONER | OTHER | N21972 | 01 | ID | NURSING LICENSE | OTHER |