MEDICARE: DEREK DRAGON

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	2255A2300X	Athletic Trainer
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1568076925
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK DRAGON

Provider Business Mailing Address
First Line	:	1319 SCHOOL HOUSE RD
Second Line	:
City	:	HARVEYS LAKE
State	:	PA
Zip	:	18618-2135
Country	:	US
Telephone Number	:	570-592-0202
Fax Number	:

Provider Business Practice Location Address
First Line	:	1319 SCHOOL HOUSE RD
Second Line	:
City	:	HARVEYS LAKE
State	:	PA
Zip	:	18618-2135
Country	:	US
Telephone Number	:	570-592-0202
Fax Number	:

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

Provider Enumeration Date	:	09/03/2020
Last Update Date	:	09/03/2020

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