Provider Demographics
NPI:1588409478
Name:PACK, BLAKE EVAN (DO)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:EVAN
Last Name:PACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 RURAL ACRES DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3503
Mailing Address - Country:US
Mailing Address - Phone:304-252-8555
Mailing Address - Fax:
Practice Address - Street 1:252 RURAL ACRES DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3503
Practice Address - Country:US
Practice Address - Phone:304-252-8555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVED1327207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine