Provider Demographics
NPI:1306116421
Name:MAYNARD, JOHN RYAN (PA)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:RYAN
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-358-0308
Mailing Address - Fax:704-358-0039
Practice Address - Street 1:2826 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1386
Practice Address - Country:US
Practice Address - Phone:704-358-0308
Practice Address - Fax:704-358-0039
Is Sole Proprietor?:No
Enumeration Date:2012-01-05
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03233363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant