Healthcare Provider Details

I. General information

NPI: 1154805372
Provider Name (Legal Business Name): MRS. KELLY ELAINE DRAGO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 UNIVERSITY BLVD
GALVESTON TX
77555-5302
US

IV. Provider business mailing address

PO BOX 650859 DEPT 710
DALLAS TX
75265-2719
US

V. Phone/Fax

Practice location:
  • Phone: 409-747-1423
  • Fax:
Mailing address:
  • Phone: 409-747-6240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA12312
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: