Provider Demographics
NPI:1396042073
Name:DETHLEFS, CYNTHIA LAUREN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:LAUREN
Last Name:DETHLEFS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:CYNTHIA
Other - Middle Name:LAUREN
Other - Last Name:DETHLEFS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8080 STATE HIGHWAY 121
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75070-2900
Mailing Address - Country:US
Mailing Address - Phone:972-268-9383
Mailing Address - Fax:972-870-4925
Practice Address - Street 1:8080 STATE HIGHWAY 121
Practice Address - Street 2:SUITE 210
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75070-2900
Practice Address - Country:US
Practice Address - Phone:972-268-9383
Practice Address - Fax:972-870-4925
Is Sole Proprietor?:No
Enumeration Date:2011-02-16
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363AM0700X
TXPA07149363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX50776ZMCYMedicare PIN
TX469457YZNAMedicare PIN
TXTXB130005Medicare PIN
TX284873103Medicaid
TX284873102Medicaid
TXTXB130009Medicare PIN