Basic Information
| Provider Information | |||||||||
| NPI: | 1154404036 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DRAPER | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 OCEANGATE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908024302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624996191 | ||||||||
| FaxNumber: | 5624996171 | ||||||||
| Practice Location | |||||||||
| Address1: | 3322 BROADWAY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | EVERETT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 982014425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253486727 | ||||||||
| FaxNumber: | 4253398283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 07/02/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA10002228 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1036316 | 05 | WA | MEDICAID |