Healthcare Provider Details

I. General information

NPI: 1124337803
Provider Name (Legal Business Name): JON DRAKE AUD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2010
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7001 PROSPECT PL NE
ALBUQUERQUE NM
87110-4311
US

IV. Provider business mailing address

701 OAKLAND HILLS LN
KERRVILLE TX
78028-6429
US

V. Phone/Fax

Practice location:
  • Phone: 505-764-0036
  • Fax: 505-764-0446
Mailing address:
  • Phone: 830-385-2034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number80582
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: