Provider Demographics
NPI:1356314736
Name:DRAKE, DANIEL E (PAC)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:E
Last Name:DRAKE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLY HILL
Mailing Address - State:FL
Mailing Address - Zip Code:32117-2360
Mailing Address - Country:US
Mailing Address - Phone:863-676-7172
Mailing Address - Fax:
Practice Address - Street 1:1340 RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:HOLLY HILL
Practice Address - State:FL
Practice Address - Zip Code:32117-2360
Practice Address - Country:US
Practice Address - Phone:866-767-1723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101408363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P23522Medicare UPIN
FLE5026YMedicare ID - Type Unspecified