Provider Demographics
NPI:1346695533
Name:MAYNARD, NATHAN C (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:C
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 EXECUTIVE PARKWAY DR STE 218
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6357
Mailing Address - Country:US
Mailing Address - Phone:314-996-8139
Mailing Address - Fax:
Practice Address - Street 1:955 EXECUTIVE PARKWAY DR STE 218
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6357
Practice Address - Country:US
Practice Address - Phone:314-996-8139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-26
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960043992255A2300X
MO390200000X
MO20190201572255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program