Healthcare Provider Details

I. General information

NPI: 1205398138
Provider Name (Legal Business Name): CYNTHIA WASHBURN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2019
Last Update Date: 02/24/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238 E 6TH ST
LOS ANGELES CA
90014-2142
US

IV. Provider business mailing address

3439 SE HAWTHORNE BLVD # 419
PORTLAND OR
97214-5048
US

V. Phone/Fax

Practice location:
  • Phone: 844-804-0055
  • Fax:
Mailing address:
  • Phone: 510-599-4966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number58875
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: