Provider Demographics
NPI:1942618657
Name:MAYNARD, TIMOTHY
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
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:PO BOX 4100
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504-4100
Mailing Address - Country:US
Mailing Address - Phone:304-908-1204
Mailing Address - Fax:304-908-1224
Practice Address - Street 1:402 C STREET
Practice Address - Street 2:
Practice Address - City:CEREDO
Practice Address - State:WV
Practice Address - Zip Code:25507
Practice Address - Country:US
Practice Address - Phone:304-908-1204
Practice Address - Fax:304-908-1224
Is Sole Proprietor?:No
Enumeration Date:2014-07-25
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008802363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily