Basic Information
| Provider Information | |||||||||
| NPI: | 1114074044 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANNINEN | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 810 E 3RD ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | DURANGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813015728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9707641790 | ||||||||
| FaxNumber: | 9703757927 | ||||||||
| Practice Location | |||||||||
| Address1: | 810 E 3RD ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | DURANGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813015728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9707641790 | ||||||||
| FaxNumber: | 9703757927 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 06/26/2015 | ||||||||
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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 | 207Q00000X | 5101008368 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | DR.0051108 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4961694 | 05 | MI | MEDICAID | 51722585 | 05 | NM | MEDICAID | 839761 | 05 | AZ | MEDICAID | 1114074044 | 05 | UT | MEDICAID | 43101852 | 05 | CO | MEDICAID |