Provider Demographics
NPI:1861010613
Name:CAMPOS, CYNTHIA X (PA-C)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:X
Last Name:CAMPOS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:X
Other - Last Name:CAMPOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:192 W WATER ST
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:MA
Mailing Address - Zip Code:02370-2449
Mailing Address - Country:US
Mailing Address - Phone:781-724-8601
Mailing Address - Fax:
Practice Address - Street 1:234 COPELAND ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-4081
Practice Address - Country:US
Practice Address - Phone:617-479-4545
Practice Address - Fax:617-472-6947
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-08
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1861010613Medicaid