Healthcare Provider Details

I. General information

NPI: 1356499255
Provider Name (Legal Business Name): DOUGLAS A DRAKE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 09/12/2025
Certification Date: 09/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27412 ENTERPRISE CIR W STE 102
TEMECULA CA
92590-4801
US

IV. Provider business mailing address

27412 ENTERPRISE CIR W STE 102
TEMECULA CA
92590-4801
US

V. Phone/Fax

Practice location:
  • Phone: 951-694-6367
  • Fax: 951-694-1428
Mailing address:
  • Phone: 951-694-6367
  • Fax: 951-694-1428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA12158
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: