Provider Demographics
NPI:1578279758
Name:MAYNARD, TYLER S
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:S
Last Name:MAYNARD
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 1:4660 SPYRES WAY
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9804
Mailing Address - Country:US
Mailing Address - Phone:209-578-3290
Mailing Address - Fax:209-550-4944
Practice Address - Street 1:4660 SPYRES WAY
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-9804
Practice Address - Country:US
Practice Address - Phone:209-578-3290
Practice Address - Fax:209-550-4944
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT299860225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist