Provider Demographics
NPI:1962494716
Name:MAYNARD, SEAN E (PA-C)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:E
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 1:67 KINGSWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-9647
Mailing Address - Country:US
Mailing Address - Phone:270-465-3812
Mailing Address - Fax:270-465-8352
Practice Address - Street 1:73 KINGSWOOD DR
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-9604
Practice Address - Country:US
Practice Address - Phone:270-849-2379
Practice Address - Fax:270-465-2126
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA592207R00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9500143400Medicaid
KY9500143400Medicaid
KY1383804Medicare PIN