Healthcare Provider Details

I. General information

NPI: 1407305659
Provider Name (Legal Business Name): MATTHEW JAMES MAYNARD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2016
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 GORMAN AVE
ELKINS WV
26241-3181
US

IV. Provider business mailing address

812 GORMAN AVE
ELKINS WV
26241-3181
US

V. Phone/Fax

Practice location:
  • Phone: 304-637-3533
  • Fax:
Mailing address:
  • Phone: 304-637-3533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2783
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2022
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: