Healthcare Provider Details

I. General information

NPI: 1356314736
Provider Name (Legal Business Name): DANIEL E DRAKE PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 RIDGEWOOD AVE
HOLLY HILL FL
32117-2360
US

IV. Provider business mailing address

1340 RIDGEWOOD AVE
HOLLY HILL FL
32117-2360
US

V. Phone/Fax

Practice location:
  • Phone: 866-767-1723
  • Fax:
Mailing address:
  • Phone: 863-676-7172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9101408
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: