Provider Demographics
NPI:1134300932
Name:MAYNARD, ALLEN (PA-C)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17401 KENTUCKY HWY 80 EAST
Mailing Address - Street 2:
Mailing Address - City:ELKHORN CITY
Mailing Address - State:KY
Mailing Address - Zip Code:41522-8210
Mailing Address - Country:US
Mailing Address - Phone:606-754-3131
Mailing Address - Fax:606-754-4554
Practice Address - Street 1:17401 KENTUCKY HWY 80 EAST
Practice Address - Street 2:
Practice Address - City:ELKHORN CITY
Practice Address - State:KY
Practice Address - Zip Code:41522-8210
Practice Address - Country:US
Practice Address - Phone:606-754-3131
Practice Address - Fax:606-754-4554
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA9532081P2900X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP0131826OtherRR MEDICARE PTAN
KY71000055500Medicaid
KY71000055500Medicaid