Healthcare Provider Details

I. General information

NPI: 1336893684
Provider Name (Legal Business Name): ELTA DESVARISTES PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2022
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13960 PLANTATION RD
FORT MYERS FL
33912-4303
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-1700
  • Fax: 239-343-1743
Mailing address:
  • Phone: 239-343-1700
  • Fax: 239-343-1743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9115630
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: