Provider Demographics
NPI:1528000809
Name:PANTANO, RICHARD (CRNA)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:PANTANO
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32962-1592
Mailing Address - Country:US
Mailing Address - Phone:772-564-8828
Mailing Address - Fax:772-564-8828
Practice Address - Street 1:110 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2828
Practice Address - Country:US
Practice Address - Phone:407-667-0444
Practice Address - Fax:407-667-4338
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2918512367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU5237ZMedicare ID - Type Unspecified