Provider Demographics
NPI:1487130795
Name:DRAEGER, GRANT P (DC)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:P
Last Name:DRAEGER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 CORMIER RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-4706
Mailing Address - Country:US
Mailing Address - Phone:920-569-2350
Mailing Address - Fax:
Practice Address - Street 1:880 S VIEW DR STE 15230
Practice Address - Street 2:
Practice Address - City:MOSINEE
Practice Address - State:WI
Practice Address - Zip Code:54455-8205
Practice Address - Country:US
Practice Address - Phone:715-203-0471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5353111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor