Healthcare Provider Details

I. General information

NPI: 1285701870
Provider Name (Legal Business Name): AVERA MCKENNAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 05/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 E HOLLY BLVD
BRANDON SD
57005-1426
US

IV. Provider business mailing address

PO BOX 86430
SIOUX FALLS SD
57118-6430
US

V. Phone/Fax

Practice location:
  • Phone: 605-582-3853
  • Fax: 605-582-3855
Mailing address:
  • Phone: 605-322-4900
  • Fax: 605-322-4910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JULIE N NORTON
Title or Position: SR VICE PRESIDENT OF FINANCE
Credential:
Phone: 605-322-7818