Provider Demographics
NPI:1811642507
Name:GARDNER, DRAKE EVAN
Entity type:Individual
Prefix:
First Name:DRAKE
Middle Name:EVAN
Last Name:GARDNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 E WILL ROGERS BLVD
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-6303
Mailing Address - Country:US
Mailing Address - Phone:918-407-8188
Mailing Address - Fax:
Practice Address - Street 1:900 E WILL ROGERS BLVD
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-6303
Practice Address - Country:US
Practice Address - Phone:918-407-8188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4471111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor