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General NPI Number Information
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NPI Number | 1285814616
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Entity Type | Individual
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Provider Name | IVAN IVANOVICH DRAZEK PA-C
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Gender | Male
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Dates
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Enumeration Date | 11/14/2007
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Last Update Date | 05/01/2008
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Provider Practice Location Address
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Address Line | 103 VICEROY DR
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City | CAMILLUS
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State | NY
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Zip | 13031-3001
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Country | US
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Telephone | 315-882-4923
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Fax |
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Provider Business Mailing Address
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Address Line | 103 VICEROY DR
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City | CAMILLUS
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State | NY
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Zip | 13031-3001
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Country | US
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Telephone | 315-882-4923
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 1074875
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License Number State | NY
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