Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2081P2900X | Pain Medicine | PA953 | KY |
NPI | 1134300932 |
---|---|
Provider Name | Allen Maynard |
First Address | Elkhorn City, KY 41522-8210 |
Second Address | Elkhorn City, KY 41522-8210 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/11/2007 |
Last Update Date | 16/07/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
71000055500 | (05) | KY |
P0131826 | RR MEDICARE PTAN (01) | KY |