Provider Demographics
NPI:1730177502
Name:FAHEY, CYNTHIA ANN (PAC)
Entity type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:ANN
Last Name:FAHEY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:CYNTHIA
Other - Middle Name:ANN
Other - Last Name:FERRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:799 HOPE ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-3635
Mailing Address - Country:US
Mailing Address - Phone:508-479-1632
Mailing Address - Fax:
Practice Address - Street 1:799 HOPE ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-3635
Practice Address - Country:US
Practice Address - Phone:508-479-1632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00575363A00000X
MA1563363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P77857Medicare UPIN
MAAP1875Medicare ID - Type Unspecified