Healthcare Provider Details

I. General information

NPI: 1962494716
Provider Name (Legal Business Name): SEAN E MAYNARD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 02/27/2024
Certification Date: 02/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73 KINGSWOOD DR
CAMPBELLSVILLE KY
42718-9604
US

IV. Provider business mailing address

67 KINGSWOOD DR
CAMPBELLSVILLE KY
42718-9647
US

V. Phone/Fax

Practice location:
  • Phone: 270-849-2379
  • Fax: 270-465-2126
Mailing address:
  • Phone: 270-465-3812
  • Fax: 270-465-8352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA592
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberPA592
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: