Provider Demographics
NPI:1861476673
Name:DRIESSE, KENDALL PETER (CRNA)
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:PETER
Last Name:DRIESSE
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 1:18123 REGENTS SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2291
Mailing Address - Country:US
Mailing Address - Phone:813-919-9797
Mailing Address - Fax:
Practice Address - Street 1:2 COLUMBIA DR
Practice Address - Street 2:SUITE A327
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3508
Practice Address - Country:US
Practice Address - Phone:813-844-4434
Practice Address - Fax:813-844-4467
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1427812367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG2003OtherBCBS
FLG2003YMedicare ID - Type UnspecifiedFGTBA M/CARE PROVIDER #
FLG2003ZMedicare ID - Type UnspecifiedGTB M/CARD PROVIDER #
FLG2003Medicare ID - Type Unspecified