Basic Information
| Provider Information | |||||||||
| NPI: | 1417555079 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURGESS | ||||||||
| FirstName: | DRAKE | ||||||||
| MiddleName: | KINGDON | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7830 W HIGH STREET EXT | ||||||||
| Address2: | |||||||||
| City: | UNION CITY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 164387630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143926081 | ||||||||
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| Practice Location | |||||||||
| Address1: | 736 IRVING AVE | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154707111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2020 | ||||||||
| LastUpdateDate: | 10/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.