Healthcare Provider Details

I. General information

NPI: 1396737391
Provider Name (Legal Business Name): MAYNARD SHAWN GONTER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 04/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E DAWSON ST
TYLER TX
75701-2036
US

IV. Provider business mailing address

PO BOX 846098
DALLAS TX
75284-6098
US

V. Phone/Fax

Practice location:
  • Phone: 903-567-4841
  • Fax:
Mailing address:
  • Phone: 903-324-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAO1417
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: