Provider Demographics
NPI:1104274760
Name:KRAYSSA SURGICAL ASSIST, PA
Entity type:Organization
Organization Name:KRAYSSA SURGICAL ASSIST, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:WATFA
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAYSSA
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:954-648-7850
Mailing Address - Street 1:601 NW 82ND AVE APT 331
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-1397
Mailing Address - Country:US
Mailing Address - Phone:954-648-7850
Mailing Address - Fax:
Practice Address - Street 1:601 NW 82ND AVE APT 331
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-1397
Practice Address - Country:US
Practice Address - Phone:954-648-7850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104341363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty