Provider Demographics
NPI:1700888021
Name:LORD, CYNTHIA BOOTH (PA-C)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:BOOTH
Last Name:LORD
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 1:2 LEE RD
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:CT
Mailing Address - Zip Code:06351
Mailing Address - Country:US
Mailing Address - Phone:860-376-4451
Mailing Address - Fax:860-376-5977
Practice Address - Street 1:2 LEE RD
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:CT
Practice Address - Zip Code:06351
Practice Address - Country:US
Practice Address - Phone:860-376-4451
Practice Address - Fax:860-376-5977
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000055363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
2V3813OtherHEALTHNET
290000055CT01OtherBCBS
2V3813OtherHEALTHNET
S58706Medicare UPIN