Provider Demographics
NPI:1205398138
Name:WASHBURN, CYNTHIA
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:WASHBURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3439 SE HAWTHORNE BLVD # 419
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-5048
Mailing Address - Country:US
Mailing Address - Phone:510-599-4966
Mailing Address - Fax:
Practice Address - Street 1:238 E 6TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90014-2142
Practice Address - Country:US
Practice Address - Phone:844-804-0055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-01
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA58875363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program