Provider Demographics
NPI:1831143833
Name:DANIEL, CYNTHIA L (PA-C)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:L
Last Name:DANIEL
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:PO BOX 568
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40702-0568
Mailing Address - Country:US
Mailing Address - Phone:606-528-7010
Mailing Address - Fax:
Practice Address - Street 1:1203 AMERICAN GREETING CARD RD
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-4811
Practice Address - Country:US
Practice Address - Phone:606-528-7010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1596363A00000X
NY007441363A00000X
TN1803363AM0700X
KYTC487363A00000X
KYPA2110363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100429590Medicaid
TN1520901OtherTENNESSEE MEDICAID/TENNCARE PROGRAM
TN1520901Medicaid
TN1520901Medicaid
P15672Medicare UPIN
KYK205550Medicare PIN