Provider Demographics
NPI:1629128483
Name:BLAIR, VICTORIA L (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:L
Last Name:BLAIR
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1783
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-1783
Mailing Address - Country:US
Mailing Address - Phone:208-552-8774
Mailing Address - Fax:208-523-2025
Practice Address - Street 1:2001 S WOODRUFF AVE STE 15B
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6372
Practice Address - Country:US
Practice Address - Phone:208-357-4633
Practice Address - Fax:208-419-0690
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN21972363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDNP772AOtherNURSE PRACTITIONER
IDN21972OtherNURSING LICENSE