Provider Demographics
NPI:1568473247
Name:BLAKE-NAFUS, VICKI (PA)
Entity Type:Individual
Prefix:MS
First Name:VICKI
Middle Name:
Last Name:BLAKE-NAFUS
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 1:100 MAC LANE
Mailing Address - Street 2:AVERA MEDICAL GROUP PIERRE
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501
Mailing Address - Country:US
Mailing Address - Phone:605-945-5348
Mailing Address - Fax:605-747-5348
Practice Address - Street 1:100 MAC LANE
Practice Address - Street 2:AVERA MEDICAL GROUP PIERRE
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501
Practice Address - Country:US
Practice Address - Phone:605-945-5348
Practice Address - Fax:605-747-5348
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0218363A00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6820185Medicaid
SD6820185Medicaid