Provider Demographics
NPI:1699304105
Name:KOENIG, CYNTHIA ANNE (PAC)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:ANNE
Last Name:KOENIG
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:
Other - Last Name:BETZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 7527
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-0727
Mailing Address - Country:US
Mailing Address - Phone:419-520-2495
Mailing Address - Fax:
Practice Address - Street 1:6905 HOSPITAL DR STE 130
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43016-9600
Practice Address - Country:US
Practice Address - Phone:149-230-3006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH50.006605RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0470672Medicaid