Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2081P2900X | Pain Medicine | O-1469 | ID |
Y | 208D00000X | General Practice Physician | O-1469 | ID |
NPI | 1083153910 |
---|---|
Provider Name | Grant Drake |
First Address | Boise, ID 83706-5053 |
Second Address | Post Falls, ID 83854-7787 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/02/2017 |
Last Update Date | 01/07/2021 |