Provider Demographics
NPI:1164928602
Name:MYNARD, JAMES NATHAN
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:NATHAN
Last Name:MYNARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 KNOX RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONS GAP
Mailing Address - State:AL
Mailing Address - Zip Code:36861-3758
Mailing Address - Country:US
Mailing Address - Phone:850-326-0978
Mailing Address - Fax:
Practice Address - Street 1:525 E 68TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4870
Practice Address - Country:US
Practice Address - Phone:646-962-8413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program