Provider Demographics
NPI:1437025715
Name:DRAKE, JARED KYLE (PA-C)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:KYLE
Last Name:DRAKE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 ROYALE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-8419
Mailing Address - Country:US
Mailing Address - Phone:585-755-8808
Mailing Address - Fax:
Practice Address - Street 1:100 PARAMOUNT BLVD
Practice Address - Street 2:
Practice Address - City:ORWIGSBURG
Practice Address - State:PA
Practice Address - Zip Code:17961-2202
Practice Address - Country:US
Practice Address - Phone:866-785-8537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-14
Last Update Date:2025-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA067188363A00000X
PAOA007480363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant