Provider Demographics
NPI:1912453564
Name:NERVEZA, DRAKE ALVIN KAPONO
Entity Type:Individual
Prefix:
First Name:DRAKE
Middle Name:ALVIN KAPONO
Last Name:NERVEZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3822 S CLARE DR
Mailing Address - Street 2:C4
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-5773
Mailing Address - Country:US
Mailing Address - Phone:808-987-9459
Mailing Address - Fax:
Practice Address - Street 1:344 EAST 100 SOUTH
Practice Address - Street 2:STE 301
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111
Practice Address - Country:US
Practice Address - Phone:801-322-4257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker