Basic Information
| Provider Information | |||||||||
| NPI: | 1053962258 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DRISCOLL | ||||||||
| FirstName: | PANDORA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25644 NW 9TH AVE | ||||||||
| Address2: | |||||||||
| City: | NEWBERRY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326693527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632215905 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1515 SW ARCHER RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326081134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522650111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2019 | ||||||||
| LastUpdateDate: | 09/27/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APRN11004136 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1234 | 05 | FL | MEDICAID |