Basic Information
| Provider Information | |||||||||
| NPI: | 1417908518 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GOULD | ||||||||
| OtherFirstName: | CYNTHIA | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1803 MT ROSE AVE | ||||||||
| Address2: | SUITE B3 | ||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174033051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178511405 | ||||||||
| FaxNumber: | 7178516969 | ||||||||
| Practice Location | |||||||||
| Address1: | 212 ROSEDALE DR | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173451023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178515503 | ||||||||
| FaxNumber: | 7178511905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2006 | ||||||||
| LastUpdateDate: | 03/18/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | SP008018 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0200X | SP008018 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 210560 | 01 | PA | JOHNS HOPKINS | OTHER | 930955 | 01 | MD | CAREFIRST MD BCBS | OTHER | 50078166 | 01 | PA | CAPITAL BLUE CROSS-WMG | OTHER | 1876086 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 1551757 | 01 | PA | GATEWAY-WMG | OTHER |