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General NPI Number Information
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NPI Number | 1295089316
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Entity Type | Individual
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Provider Name | KRYSTA JEAN DEFTY PA-C
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Gender | Female
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Dates
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Enumeration Date | 10/29/2012
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Last Update Date | 12/14/2016
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Provider Practice Location Address
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Address Line | 13770 PLANTATION RD SUITE 2
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City | FORT MYERS
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State | FL
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Zip | 33912-4460
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Country | US
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Telephone | 239-275-0728
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Fax | 239-275-6947
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Provider Business Mailing Address
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Address Line | 2234 COLONIAL BLVD
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City | FORT MYERS
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State | FL
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Zip | 33907-1412
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Country | US
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Telephone | 239-931-7342
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Fax | 239-931-7385
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA9106963
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License Number State | FL
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