Provider Demographics
NPI:1952398737
Name:WASEK, CYNTHIA PHYLLIS
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:PHYLLIS
Last Name:WASEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:P
Other - Last Name:BUTTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:2204 E 3715 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-3338
Mailing Address - Country:US
Mailing Address - Phone:801-824-2185
Mailing Address - Fax:866-855-3582
Practice Address - Street 1:4376 S 700 E STE 200
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-3077
Practice Address - Country:US
Practice Address - Phone:385-272-4292
Practice Address - Fax:866-855-3582
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2001478900363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1952398737Medicaid
UT1952398737Medicaid
UTU000094048Medicare PIN