Basic Information
| Provider Information | |||||||||
| NPI: | 1699050096 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2153 DEPT 40339 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352879387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062710100 | ||||||||
| FaxNumber: | 7062700487 | ||||||||
| Practice Location | |||||||||
| Address1: | 4800 W 25TH ST | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806343734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703306400 | ||||||||
| FaxNumber: | 7062700487 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2011 | ||||||||
| LastUpdateDate: | 06/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 3307 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 21920851 | 05 | CO | MEDICAID |