Healthcare Provider Details

I. General information

NPI: 1548072820
Provider Name (Legal Business Name): KASSIDY RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2025
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 VONDERBURG DR STE 102
BRANDON FL
33511-5968
US

IV. Provider business mailing address

500 VONDERBURG DR STE 102
BRANDON FL
33511-5968
US

V. Phone/Fax

Practice location:
  • Phone: 813-681-5658
  • Fax: 813-681-5250
Mailing address:
  • Phone: 813-681-5658
  • Fax: 813-681-5250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9119920
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: