Provider Demographics
NPI:1639234016
Name:PAPADOPOULOS, CYNTHIA LEE (PAC)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:LEE
Last Name:PAPADOPOULOS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:L
Other - Last Name:GLASGOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-314-4300
Mailing Address - Fax:
Practice Address - Street 1:181 E MEDICAL TOWER DR
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-4872
Practice Address - Country:US
Practice Address - Phone:801-413-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8983549-1206363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT8983549-1206OtherMEDICAL LICENSE
S85260Medicare UPIN
NV002404042Medicaid
UT8983549-8906OtherCONTROLLED SUBSTANCE PHARM LIC
NVY39496Medicare ID - Type Unspecified
UTMG3212153OtherDEA