Provider Demographics
NPI:1952491284
Name:DICKINSON, CYNTHIA K
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:K
Last Name:DICKINSON
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 1:200 E PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3089
Mailing Address - Country:US
Mailing Address - Phone:309-655-7900
Mailing Address - Fax:309-655-7903
Practice Address - Street 1:200 E PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3089
Practice Address - Country:US
Practice Address - Phone:309-655-7900
Practice Address - Fax:309-655-7903
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041141001/209001084363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S69904Medicare UPIN
ILK36908Medicare ID - Type UnspecifiedINDIVIDUAL # (EFF 5-22-07
ILCA4079Medicare ID - Type UnspecifiedRR GROUP #
IL809840Medicare ID - Type UnspecifiedGROUP #
IL952320Medicare ID - Type UnspecifiedINDIVIDUAL #