Basic Information
| Provider Information | |||||||||
| NPI: | 1255350765 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERGUSON | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 936 | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235010936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574465626 | ||||||||
| FaxNumber: | 7574466000 | ||||||||
| Practice Location | |||||||||
| Address1: | 721 FAIRFAX AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235072007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574465629 | ||||||||
| FaxNumber: | 7574466000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 01/04/2012 | ||||||||
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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 | 363A00000X | 0110840865 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | -005 | 01 | VA | TRICARE/CHAMPUS | OTHER | PAR | 01 | VA | CORVEL/CORCARE | OTHER | 1255350765 | 05 | VA | MEDICAID | 8101062 | 05 | NC | MEDICAID | 10049273P | 01 | VA | SENTARA/OPTIMA HEALTH | OTHER | PAR | 01 | VA | MULTIPLAN | OTHER | PAR | 01 | VA | USA MANAGED CARE | OTHER |