Provider Demographics
NPI:1477595452
Name:MAYNARD, ALAN MICHAEL (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:ALAN
Middle Name:MICHAEL
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 1:42 CRYSTAL RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VT
Mailing Address - Zip Code:05454-9572
Mailing Address - Country:US
Mailing Address - Phone:802-656-7678
Mailing Address - Fax:
Practice Address - Street 1:213A PATRICK GYMNASIUM
Practice Address - Street 2:97 SPEAR ST.
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05405-0001
Practice Address - Country:US
Practice Address - Phone:802-656-7678
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1040000092174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist