Basic Information
Provider Information | |||||||||
NPI: | 1730541202 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DRAPER | ||||||||
FirstName: | IESHA | ||||||||
MiddleName: | SCHANAE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CLAY | ||||||||
OtherFirstName: | IESHA | ||||||||
OtherMiddleName: | SCHANAE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1800 COMMUNITY | ||||||||
Address2: |   | ||||||||
City: | CLINTON | ||||||||
State: | MO | ||||||||
PostalCode: | 647358804 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6608908156 | ||||||||
FaxNumber: | 6608908156 | ||||||||
Practice Location | |||||||||
Address1: | 1032 CROSSWINDS CT | ||||||||
Address2: |   | ||||||||
City: | WENTZVILLE | ||||||||
State: | MO | ||||||||
PostalCode: | 633854836 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6363326000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/24/2016 | ||||||||
LastUpdateDate: | 06/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 2019024441 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.