Provider Demographics
NPI:1013129659
Name:TETZLAFF, CINDY ELLEN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:CINDY
Middle Name:ELLEN
Last Name:TETZLAFF
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 1:6790 FAIRCHILD ST
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-4192
Mailing Address - Country:US
Mailing Address - Phone:909-512-6612
Mailing Address - Fax:
Practice Address - Street 1:10650 SIERRA AVE STE B
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92337-7664
Practice Address - Country:US
Practice Address - Phone:909-550-3320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11644363A00000X
AZ3473363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant