Provider Demographics
NPI:1528361268
Name:GOLDRICK, CYNTHIA L (PA-C)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:L
Last Name:GOLDRICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:581 WILLIAM LATHAM DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-2317
Mailing Address - Country:US
Mailing Address - Phone:815-929-9700
Mailing Address - Fax:815-929-9797
Practice Address - Street 1:581 WILLIAM LATHAM DR
Practice Address - Street 2:SUITE 103
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2317
Practice Address - Country:US
Practice Address - Phone:815-929-9700
Practice Address - Fax:815-929-9797
Is Sole Proprietor?:No
Enumeration Date:2010-12-20
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085000881363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085000881Medicaid