Provider Demographics
NPI:1053315804
Name:BOORTZ-MARX, CYNTHIA L (CRNA)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:L
Last Name:BOORTZ-MARX
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:L
Other - Last Name:BOORTZ-MARX
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:101 MANNING DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27599
Mailing Address - Country:US
Mailing Address - Phone:919-966-6633
Mailing Address - Fax:919-966-4873
Practice Address - Street 1:101 MANNING DR
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-4220
Practice Address - Country:US
Practice Address - Phone:919-966-6633
Practice Address - Fax:919-966-4873
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI79332367500000X
NC212429367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44327900Medicaid
SCNAN626Medicaid
NC2618467OtherMEDICARE
SCNAN626Medicaid
NC2618467OtherMEDICARE