Provider Demographics
NPI:1205860798
Name:SHUMWAY, MAYNARD A (PA-C)
Entity Type:Individual
Prefix:
First Name:MAYNARD
Middle Name:A
Last Name:SHUMWAY
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 1:601 GATES RD
Mailing Address - Street 2:STE 3
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850
Mailing Address - Country:US
Mailing Address - Phone:607-584-7385
Mailing Address - Fax:607-772-1223
Practice Address - Street 1:110 LOMOND CT
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-5950
Practice Address - Country:US
Practice Address - Phone:315-292-1264
Practice Address - Fax:315-266-0385
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001412363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03324334Medicaid
NYJ400037464Medicare PIN