Provider Demographics
NPI:1225053630
Name:HOLMES, CYNTHIA S (MD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:S
Last Name:HOLMES
Suffix:
Gender:F
Credentials:MD
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 1535
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98401-1535
Mailing Address - Country:US
Mailing Address - Phone:253-761-4200
Mailing Address - Fax:253-383-3553
Practice Address - Street 1:1304 FAWCETT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-1911
Practice Address - Country:US
Practice Address - Phone:253-761-4200
Practice Address - Fax:253-383-3553
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR241382085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286306Medicaid
ID806564700Medicaid
WA1117654Medicaid
ORR174172OtherPTAN-PENDLETON, OREGON
ORG42124Medicare UPIN
OR286306Medicaid
ORR114533Medicare PIN