Provider Demographics
NPI:1407305659
Name:MAYNARD, MATTHEW JAMES (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
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 1:812 GORMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-3181
Mailing Address - Country:US
Mailing Address - Phone:304-637-3533
Mailing Address - Fax:
Practice Address - Street 1:812 GORMAN AVE
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3181
Practice Address - Country:US
Practice Address - Phone:304-637-3533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-29
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2783363AM0700X
WV2022363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical