Provider Demographics
NPI:1790120129
Name:MICK G DRAGE LLC
Entity Type:Organization
Organization Name:MICK G DRAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICKY
Authorized Official - Middle Name:G
Authorized Official - Last Name:DRAGE
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:928-348-1370
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2585363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ639354Medicaid