Basic Information
| Provider Information | |||||||||
| NPI: | 1861476673 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DRIESSE | ||||||||
| FirstName: | KENDALL | ||||||||
| MiddleName: | PETER | ||||||||
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| Credential: | C.R.N.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18123 REGENTS SQUARE DR | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336472291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139199797 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2 COLUMBIA DR | ||||||||
| Address2: | SUITE A327 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336063508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138444434 | ||||||||
| FaxNumber: | 8138444467 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | ARNP1427812 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | G2003 | 01 | FL | BCBS | OTHER |