Provider Demographics
NPI:1295089316
Name:DEFTY, KRYSTA JEAN (PA-C)
Entity type:Individual
Prefix:
First Name:KRYSTA
Middle Name:JEAN
Last Name:DEFTY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRYSTA
Other - Middle Name:JEAN
Other - Last Name:THOLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:13770 PLANTATION RD
Practice Address - Street 2:SUITE 2
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4460
Practice Address - Country:US
Practice Address - Phone:239-275-0728
Practice Address - Fax:239-275-6947
Is Sole Proprietor?:No
Enumeration Date:2012-10-29
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106963363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007345500Medicaid
FL1249031OtherWELLCARE
FL5296786OtherAETNA
FLP951597OtherOPTIMUM
FL1720187OtherCIGNA
FL398581OtherAVMED
FLP01480233OtherRR MEDICARE
FLP1004057OtherFREEDOM
FLY0F3COtherBCBS FL INDIVIDUAL PROVIDER ID #
FL007345500Medicaid