MEDICARE: MR. JOHN VAYDEN BLAKE PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	202	WV
2	363A00000X	Physician Assistant	929	WV

General Provider Information

NPI Number	:	1013994953
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN VAYDEN BLAKE PA

Provider Business Mailing Address
First Line	:	497 MALL RD
Second Line	:
City	:	OAK HILL
State	:	WV
Zip	:	25901-6216
Country	:	US
Telephone Number	:	304-469-2905
Fax Number	:	304-465-5486

Provider Business Practice Location Address
First Line	:	315 FAIRVIEW HEIGHTS RD
Second Line	:
City	:	SUMMERSVILLE
State	:	WV
Zip	:	26651-1086
Country	:	US
Telephone Number	:	304-469-2905
Fax Number	:	304-465-5486

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/30/2005
Last Update Date	:	01/03/2025

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