Healthcare Provider Details

I. General information

NPI: 1275955775
Provider Name (Legal Business Name): CYNTHIA OQUENDO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2014
Last Update Date: 06/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3075 BRECKINRIDGE BLVD STE 415
DULUTH GA
30096-7612
US

IV. Provider business mailing address

1027 MCGILL PARK AVE NE
ATLANTA GA
30312-1289
US

V. Phone/Fax

Practice location:
  • Phone: 770-962-8396
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: