Healthcare Provider Details

I. General information

NPI: 1083197420
Provider Name (Legal Business Name): KRISTINA DANIELA MCCOLGAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2018
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2776 CLEVELAND AVE
FORT MYERS FL
33901-5864
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-3292
  • Fax: 239-343-3695
Mailing address:
  • Phone: 239-343-3292
  • Fax: 239-343-3695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9111580
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9111580
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: