Healthcare Provider Details

I. General information

NPI: 1003662206
Provider Name (Legal Business Name): DRAUSTY PATEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2024
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4685 N COUNTY ROAD 19A
MOUNT DORA FL
32757-2039
US

IV. Provider business mailing address

410 FERN DR
LEESBURG FL
34748-7008
US

V. Phone/Fax

Practice location:
  • Phone: 352-483-0900
  • Fax: 352-483-0822
Mailing address:
  • Phone: 352-705-3484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9119119
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: