Provider Demographics
NPI:1033117874
Name:BERWALD, CYNTHIA C (PA)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:C
Last Name:BERWALD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:435-940-9400
Mailing Address - Fax:
Practice Address - Street 1:2720 HOMESTEAD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-4881
Practice Address - Country:US
Practice Address - Phone:435-940-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4948359-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000072535Medicare PIN