Provider Demographics
NPI:1194717173
Name:FORDYCE, CINDY M (PA)
Entity type:Individual
Prefix:
First Name:CINDY
Middle Name:M
Last Name:FORDYCE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5052 N CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5822
Mailing Address - Country:US
Mailing Address - Phone:260-484-8551
Mailing Address - Fax:260-482-5060
Practice Address - Street 1:5050 N CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5886
Practice Address - Country:US
Practice Address - Phone:260-484-8551
Practice Address - Fax:260-482-5060
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000277A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200029384OtherRAIL ROAD MEDICARE
IN300006073Medicaid
IN200029384Medicare PIN
INS39370Medicare UPIN
IN200029384OtherRAIL ROAD MEDICARE