MEDICARE: MARIA MAYNARD PHYSICIAN ASSISTANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	2598	OK

General Provider Information

NPI Number	:	1184080145
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA MAYNARD PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	300 WANDA ST
Second Line	:
City	:	MARIETTA
State	:	OK
Zip	:	73448-1200
Country	:	US
Telephone Number	:	580-276-3347
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 WANDA ST
Second Line	:
City	:	MARIETTA
State	:	OK
Zip	:	73448-1200
Country	:	US
Telephone Number	:	580-276-3347
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2016
Last Update Date	:	01/06/2016

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