Provider Demographics
NPI:1013353960
Name:HADRA, KRYSTINA MARIAN (PA)
Entity type:Individual
Prefix:
First Name:KRYSTINA
Middle Name:MARIAN
Last Name:HADRA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRYSTINA
Other - Middle Name:M
Other - Last Name:MAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 25487
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34277-2487
Mailing Address - Country:US
Mailing Address - Phone:941-202-5342
Mailing Address - Fax:855-253-4836
Practice Address - Street 1:4502 CORTEZ RD W STE 205
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-3124
Practice Address - Country:US
Practice Address - Phone:941-259-8505
Practice Address - Fax:941-259-8501
Is Sole Proprietor?:No
Enumeration Date:2013-05-20
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0Q91OtherBCBS
FL016921400Medicaid