Provider Demographics
NPI:1538130216
Name:TRICKETT, CYNTHIA JEAN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:JEAN
Last Name:TRICKETT
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 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:8144 WALNUT HILL LN STE 1300
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4365
Practice Address - Country:US
Practice Address - Phone:214-420-7070
Practice Address - Fax:214-420-7380
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01467363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G3896Medicare ID - Type UnspecifiedTRAILBLAZERS INDIVIDUAL N
S50748Medicare UPIN