Provider Demographics
NPI:1265495535
Name:ANDERSON, CYNTHIA A
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:A
Last Name:ANDERSON
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 1:2820 MOUNT RUSHMORE RD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-5462
Mailing Address - Country:US
Mailing Address - Phone:605-721-8354
Mailing Address - Fax:605-721-8458
Practice Address - Street 1:2820 MOUNT RUSHMORE RD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-5462
Practice Address - Country:US
Practice Address - Phone:605-721-8354
Practice Address - Fax:605-721-8458
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9503207N00000X
SD0726363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
S66681Medicare UPIN