Basic Information
| Provider Information | |||||||||
| NPI: | 1578528931 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAWRENCE | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | JUNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 345 MAXWELL AVE | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803043972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035445783 | ||||||||
| FaxNumber: | 3034412388 | ||||||||
| Practice Location | |||||||||
| Address1: | 2995 BASELINE RD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803032318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034432544 | ||||||||
| FaxNumber: | 3034436476 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 11/15/2013 | ||||||||
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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 | 363AM0700X | 110 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 06971881 | 05 | CO | MEDICAID |