Provider Demographics
NPI:1437308301
Name:DRAKE, KELLY (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DRAKE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 W AGUA FRIA FWY STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-3944
Mailing Address - Country:US
Mailing Address - Phone:623-537-5600
Mailing Address - Fax:
Practice Address - Street 1:2730 W AGUA FRIA FWY
Practice Address - Street 2:STE 100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-7201
Practice Address - Country:US
Practice Address - Phone:623-537-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12203277-1206363A00000X
AZ4318363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ379670Medicaid