Provider Demographics
NPI:1497708952
Name:KESSACK, ROBERT O III (PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:O
Last Name:KESSACK
Suffix:III
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 FREDERICK ST
Mailing Address - Street 2:
Mailing Address - City:PIERSON
Mailing Address - State:FL
Mailing Address - Zip Code:32180-3024
Mailing Address - Country:US
Mailing Address - Phone:386-749-9449
Mailing Address - Fax:386-749-2280
Practice Address - Street 1:216 FREDERICK ST
Practice Address - Street 2:
Practice Address - City:PIERSON
Practice Address - State:FL
Practice Address - Zip Code:32180-3024
Practice Address - Country:US
Practice Address - Phone:386-749-9449
Practice Address - Fax:386-749-2280
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105462363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9105462OtherPA LICENSE, FLORIDA
FL002724600Medicaid
FLDR493ZMedicare PIN
FLPA9105462OtherPA LICENSE, FLORIDA
FL002724600Medicaid
OHPA20196Medicare PIN