Provider Demographics
NPI:1417909862
Name:BUNDE, CYNTHIA ANN (PA)
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:ANN
Last Name:BUNDE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4520
Mailing Address - Country:US
Mailing Address - Phone:208-233-6245
Mailing Address - Fax:208-233-1065
Practice Address - Street 1:429 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4520
Practice Address - Country:US
Practice Address - Phone:208-233-6245
Practice Address - Fax:208-233-1065
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-306363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPAG74OtherBLUE CROSS OF IDAHO
ID805811300Medicaid
P00382898OtherRAILROAD MEDICARE
ID000010155655OtherREGENCE-BS OF IDAHO
ID16660051Medicare PIN
IDQ21940Medicare UPIN