Healthcare Provider Details

I. General information

NPI: 1033642228
Provider Name (Legal Business Name): PAUL DRAKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS WAY # 512-15
LITTLE ROCK AR
72202-3500
US

IV. Provider business mailing address

PO BOX 251418
LITTLE ROCK AR
72225-1418
US

V. Phone/Fax

Practice location:
  • Phone: 501-364-5281
  • Fax:
Mailing address:
  • Phone: 501-364-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE-15131
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberE-15131
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: