Provider Demographics
NPI:1831148931
Name:MAYNOR, KENRIC ALLEN (MD, MPH)
Entity type:Individual
Prefix:
First Name:KENRIC
Middle Name:ALLEN
Last Name:MAYNOR
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 HUCKLEBERRY DR
Mailing Address - Street 2:
Mailing Address - City:DURYEA
Mailing Address - State:PA
Mailing Address - Zip Code:18642-1153
Mailing Address - Country:US
Mailing Address - Phone:570-826-7300
Mailing Address - Fax:570-819-5647
Practice Address - Street 1:1000 E MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-0027
Practice Address - Country:US
Practice Address - Phone:570-826-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD62818208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD408307500Medicaid
MDN416Medicare ID - Type UnspecifiedINDIVIDUAL
MDKR65JHMedicare ID - Type UnspecifiedGROUP
MD408307500Medicaid