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
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 1112
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26555-1112
Mailing Address - Country:US
Mailing Address - Phone:304-986-1750
Mailing Address - Fax:304-986-3742
Practice Address - Street 1:118 MARKET ST
Practice Address - Street 2:
Practice Address - City:MANNINGTON
Practice Address - State:WV
Practice Address - Zip Code:26582-1131
Practice Address - Country:US
Practice Address - Phone:304-986-1750
Practice Address - Fax:304-986-3742
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV202363A00000X
WV929363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P36342Medicare UPIN