Basic Information
| Provider Information | |||||||||
| NPI: | 1447448113 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRAYSSA | ||||||||
| FirstName: | WATFA | ||||||||
| MiddleName: | EMILE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2438 E COMMERCIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333084040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547726740 | ||||||||
| FaxNumber: | 9547726703 | ||||||||
| Practice Location | |||||||||
| Address1: | 2438 E COMMERCIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333084040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547726740 | ||||||||
| FaxNumber: | 9547726703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2007 | ||||||||
| LastUpdateDate: | 03/09/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA9104341 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 34799 | 01 | FL | BCBS FL | OTHER |