Provider Demographics
NPI:1538319561
Name:SAM, CYNTHIA A (MS, APRN)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:A
Last Name:SAM
Suffix:
Gender:F
Credentials:MS, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 358
Mailing Address - Street 2:
Mailing Address - City:KREBS
Mailing Address - State:OK
Mailing Address - Zip Code:74554-0358
Mailing Address - Country:US
Mailing Address - Phone:918-424-9684
Mailing Address - Fax:
Practice Address - Street 1:530 N MONTE VISTA ST STE A
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4675
Practice Address - Country:US
Practice Address - Phone:580-310-9510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-26
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK75026363LF0000X
NM02009363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM271777YM5AOtherMEDICARE
NM91531551Medicaid