Healthcare Provider Details

I. General information

NPI: 1295089316
Provider Name (Legal Business Name): KRYSTA JEAN DEFTY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRYSTA JEAN THOLEN PA-C

II. Dates (important events)

Enumeration Date: 10/29/2012
Last Update Date: 12/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13770 PLANTATION RD SUITE 2
FORT MYERS FL
33912-4460
US

IV. Provider business mailing address

2234 COLONIAL BLVD
FORT MYERS FL
33907-1412
US

V. Phone/Fax

Practice location:
  • Phone: 239-275-0728
  • Fax: 239-275-6947
Mailing address:
  • Phone: 239-931-7342
  • Fax: 239-931-7385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9106963
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: