Provider Demographics
NPI:1013994953
Name:BLAKE, JOHN VAYDEN (PA)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:VAYDEN
Last Name:BLAKE
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:497 MALL RD
Mailing Address - Street 2:
Mailing Address - City:OAK HILL
Mailing Address - State:WV
Mailing Address - Zip Code:25901-6216
Mailing Address - Country:US
Mailing Address - Phone:304-469-2905
Mailing Address - Fax:304-465-5486
Practice Address - Street 1:315 FAIRVIEW HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-1086
Practice Address - Country:US
Practice Address - Phone:304-469-2905
Practice Address - Fax:304-465-5486
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2025-01-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WV202363A00000X
WV929363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P36342Medicare UPIN