Provider Demographics
NPI:1063775765
Name:DEJESUS, CRYSTAL (PA-C)
Entity type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:
Last Name:DEJESUS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:GUTIERREZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:7620 LAKE UNDERHILL RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-8223
Mailing Address - Country:US
Mailing Address - Phone:321-235-0692
Mailing Address - Fax:321-235-0694
Practice Address - Street 1:19735 US HIGHWAY 441 FL 1
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-2204
Practice Address - Country:US
Practice Address - Phone:352-735-5700
Practice Address - Fax:352-735-5701
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106616363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9106616OtherLICENSE
FLPA9106616OtherLICENSE