Healthcare Provider Details

I. General information

NPI: 1881693992
Provider Name (Legal Business Name): JAYNE PATRICE MAYNOR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 02/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2905 N ELM ST
LUMBERTON NC
28358-2982
US

IV. Provider business mailing address

2905 N ELM ST P O BOX 2370
LUMBERTON NC
28358-2982
US

V. Phone/Fax

Practice location:
  • Phone: 910-738-8154
  • Fax: 910-671-8818
Mailing address:
  • Phone: 910-738-8154
  • Fax: 910-671-8818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number40036
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number40036
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number40036
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: