Healthcare Provider Details

I. General information

NPI: 1679564652
Provider Name (Legal Business Name): DONALD WAYNE DRAPER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 ANDREWS AVENUE LYSTER US ARMY HEALTH CLINIC
FORT RUCKER AL
36362
US

IV. Provider business mailing address

301 ANDREWS AVENUE LYSTER US ARMY HEALTH CLINIC
FORT RUCKER AL
36362
US

V. Phone/Fax

Practice location:
  • Phone: 334-255-7387
  • Fax:
Mailing address:
  • Phone: 334-255-7387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-376
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: