Provider Demographics
NPI:1083153910
Name:DRAKE, GRANT (DO)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:DRAKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2656 S HARMONY AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-5053
Mailing Address - Country:US
Mailing Address - Phone:208-761-3080
Mailing Address - Fax:
Practice Address - Street 1:3372 E JENALAN
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-7787
Practice Address - Country:US
Practice Address - Phone:208-761-3080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-12
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-14692081P2900X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine