Healthcare Provider Details

I. General information

NPI: 1437631280
Provider Name (Legal Business Name): AVERA MCKENNAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2018
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 S LOUISE AVE
SIOUX FALLS SD
57106-2329
US

IV. Provider business mailing address

PO BOX 86370
SIOUX FALLS SD
57118-6370
US

V. Phone/Fax

Practice location:
  • Phone: 605-271-2064
  • Fax:
Mailing address:
  • Phone: 605-322-6408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DAVID FLICEK
Title or Position: CEO/PRESIDENT
Credential:
Phone: 605-322-8000