Provider Demographics
NPI:1710935499
Name:DRAGE, MICK GENE (PA-C)
Entity Type:Individual
Prefix:
First Name:MICK
Middle Name:GENE
Last Name:DRAGE
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 1:1515 S 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAFFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85546-4009
Mailing Address - Country:US
Mailing Address - Phone:928-348-1370
Mailing Address - Fax:928-348-1375
Practice Address - Street 1:1515 S 20TH AVE
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-4009
Practice Address - Country:US
Practice Address - Phone:928-348-1370
Practice Address - Fax:928-348-1375
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2585363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ639354OtherAHCCCS
AZ68095Medicare ID - Type Unspecified
AZ639354OtherAHCCCS