Provider Demographics
NPI:1710596481
Name:GARY, CYNTHIA R
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:R
Last Name:GARY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5675 N FRONT ST STE 141
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-2719
Mailing Address - Country:US
Mailing Address - Phone:267-428-6575
Mailing Address - Fax:267-262-6265
Practice Address - Street 1:5675 N FRONT ST STE 141
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120-2719
Practice Address - Country:US
Practice Address - Phone:267-428-6575
Practice Address - Fax:267-262-6265
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-28
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP021998363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty