Healthcare Provider Details

I. General information

NPI: 1205893773
Provider Name (Legal Business Name): PREETHY CYRIAC PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 OGLETOWN STANTON ROAD SUITE 5A43
NEWARK DE
19718-2200
US

IV. Provider business mailing address

2300 COMPUTER RD SUITE H-39
WILLOW GROVE PA
19090-1752
US

V. Phone/Fax

Practice location:
  • Phone: 302-623-0188
  • Fax: 302-733-5640
Mailing address:
  • Phone: 215-657-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC5-0012094
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0009539
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA051963
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: