Provider Demographics
NPI:1932150471
Name:HOLMES, CYNTHIA LOUISE (PA-C)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:LOUISE
Last Name:HOLMES
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 1:1890 WAITE ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-1229
Mailing Address - Country:US
Mailing Address - Phone:541-756-6232
Mailing Address - Fax:541-756-6234
Practice Address - Street 1:1890 WAITE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:NORTH BEND
Practice Address - State:OR
Practice Address - Zip Code:97459-1229
Practice Address - Country:US
Practice Address - Phone:541-756-6232
Practice Address - Fax:541-756-6234
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01102363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1619915113OtherWATERFALL CLINIC, INC. GROUP NPI
OR213342Medicaid
381902OtherFQHC MEDICARE NUMBER
OR213342Medicaid