Provider Demographics
NPI:1952300253
Name:MAYFIELD, GARY D (PA-C)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:D
Last Name:MAYFIELD
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 1:2200 E PARRISH AVE
Mailing Address - Street 2:C-104
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1449
Mailing Address - Country:US
Mailing Address - Phone:270-852-1632
Mailing Address - Fax:270-852-1633
Practice Address - Street 1:2200 E PARRISH AVE
Practice Address - Street 2:C-104
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1449
Practice Address - Country:US
Practice Address - Phone:270-852-1632
Practice Address - Fax:270-852-1633
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY334363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95003349Medicaid
KY95003349Medicaid
529939Medicare UPIN