Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | ME95246 | FL |
Y | 207QS0010X | Family Doctor - Sports Medicine | ME95246 | FL |
NPI | 1285610915 |
---|---|
Provider Name | Dr. Michele D. Pescasio |
First Address | Tampa, FL 33647-2989 |
Second Address | Tampa, FL 33647-2989 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/12/2005 |
Last Update Date | 03/05/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
274739100 | (05) | FL |
41002 | BLUE CROSS BLUE SHIELD (01) | FL |
G83941 | (02) | FL |