Provider Demographics
NPI:1881319598
Name:DRAKE, KRISTINE (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:DRAKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:
Other - Last Name:GALLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9124 W ROMA AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-0814
Mailing Address - Country:US
Mailing Address - Phone:586-907-7151
Mailing Address - Fax:
Practice Address - Street 1:2601 E ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-4973
Practice Address - Country:US
Practice Address - Phone:602-344-5011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-05
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9332363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant