MEDICARE: IAN THOMAS DRAKULICH LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	201230436LPN	OR

General Provider Information

NPI Number	:	1538636519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IAN THOMAS DRAKULICH LPN

Provider Business Mailing Address
First Line	:	2925 SE 87TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97266-1594
Country	:	US
Telephone Number	:	971-303-1616
Fax Number	:

Provider Business Practice Location Address
First Line	:	8517 SE 17TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97202-7347
Country	:	US
Telephone Number	:	503-542-4800
Fax Number	:	503-542-4801

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/29/2018
Last Update Date	:	10/29/2018

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