Healthcare Provider Details

I. General information

NPI: 1619383486
Provider Name (Legal Business Name): SAMUEL DRAHOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2014
Last Update Date: 07/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

788 8TH AVE SE LEVEL 4 / SUITE 400
CEDAR RAPIDS IA
52401-2107
US

IV. Provider business mailing address

1309 11TH AVE
BELLE PLAINE IA
52208-1623
US

V. Phone/Fax

Practice location:
  • Phone: 319-832-2328
  • Fax:
Mailing address:
  • Phone: 319-310-5611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA125290
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: