Basic Information
| Provider Information | |||||||||
| NPI: | 1073038790 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DRAKE | ||||||||
| FirstName: | SANDY | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10373 DUGAN GAP RD | ||||||||
| Address2: | |||||||||
| City: | NORTH BEND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450529750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135434027 | ||||||||
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| Practice Location | |||||||||
| Address1: | 375 DIXMYTH AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452202475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138659040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2017 | ||||||||
| LastUpdateDate: | 08/03/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.