Provider Demographics
NPI:1396789707
Name:FUENTES, CYNTHIA (LSA, CFA, CST)
Entity type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:
Last Name:FUENTES
Suffix:
Gender:F
Credentials:LSA, CFA, CST
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 156
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75168-0156
Mailing Address - Country:US
Mailing Address - Phone:469-231-5309
Mailing Address - Fax:972-913-0544
Practice Address - Street 1:10015 HERITAGE PL
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75217-7771
Practice Address - Country:US
Practice Address - Phone:469-231-5309
Practice Address - Fax:972-913-0544
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2017-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00072363AS0400X, 246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX89N932OtherBLUE CROSS BLUE SHEILD
TX83819OtherNCST FIRST ASST