Provider Demographics
NPI:1770817348
Name:DRAKE, DOUGLAS A (PA-C)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:A
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:PO BOX 843456
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90084-3456
Mailing Address - Country:US
Mailing Address - Phone:602-258-4788
Mailing Address - Fax:602-258-5131
Practice Address - Street 1:2900 12TH AVE N STE 140W
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-7507
Practice Address - Country:US
Practice Address - Phone:406-237-5050
Practice Address - Fax:406-272-3395
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5432363AS0400X, 363AS0400X
WAPA60162605363AS0400X
MT114160363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ835649Medicaid
1086241OtherNCCPA
AZZ161481Medicare PIN