Provider Demographics
NPI:1720020167
Name:DEMOLA, CYNTHIA A
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:A
Last Name:DEMOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:CYNTHIA
Other - Middle Name:A
Other - Last Name:DEMOLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:111 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-1909
Mailing Address - Country:US
Mailing Address - Phone:973-624-4908
Mailing Address - Fax:973-877-5595
Practice Address - Street 1:111 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-1909
Practice Address - Country:US
Practice Address - Phone:973-624-4908
Practice Address - Fax:973-877-5595
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00094400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
145938ZCVMMedicare PIN
NJP83822Medicare UPIN
NJ077857ATHMedicare PIN