Provider Demographics
NPI:1053348300
Name:WEAKS, CRYSTAL (PA-C)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:WEAKS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8010 SUMMERLIN LAKES DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1849
Mailing Address - Country:US
Mailing Address - Phone:239-939-1767
Mailing Address - Fax:239-939-5895
Practice Address - Street 1:8010 SUMMERLIN LAKES DR
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1849
Practice Address - Country:US
Practice Address - Phone:239-939-1767
Practice Address - Fax:239-939-5895
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100925363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290598100Medicaid
P00145895OtherRAILROAD MEDICARE
P00145895OtherRAILROAD MEDICARE
FL290598100Medicaid