Basic Information
Provider Information | |||||||||
NPI: | 1750335089 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DRAGO | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | P. | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RPA-C, MPAS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4526 WHITETAIL CT | ||||||||
Address2: |   | ||||||||
City: | HAMBURG | ||||||||
State: | NY | ||||||||
PostalCode: | 140755449 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7166496380 | ||||||||
FaxNumber: | 7166496380 | ||||||||
Practice Location | |||||||||
Address1: | 4535 SOUTHWESTERN BLVD | ||||||||
Address2: | SEDONA HOLISTIC MEDICAL CENTRE | ||||||||
City: | HAMBURG | ||||||||
State: | NY | ||||||||
PostalCode: | 140751860 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7166466075 | ||||||||
FaxNumber: | 7166496380 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/20/2006 | ||||||||
LastUpdateDate: | 11/10/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 006123 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 02429367 | 05 | NY |   | MEDICAID |