Provider Demographics
NPI:1033179700
Name:SMITH, CYNTHIA M (PA-C)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:M
Other - Last Name:THEOBALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3330 COBB PKWY NW STE 324-201
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-8320
Mailing Address - Country:US
Mailing Address - Phone:915-474-7675
Mailing Address - Fax:
Practice Address - Street 1:1275 HIGHWAY 54 W STE 201
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4538
Practice Address - Country:US
Practice Address - Phone:770-461-3776
Practice Address - Fax:770-461-3565
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-002328363A00000X
GA7814363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant