Provider Demographics
NPI:1346695533
Name:MAYNARD, NATHAN C (MS, LAT, ATC, CSCS)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:C
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:MS, LAT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 EXECUTIVE PARKWAY DR STE 218
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6357
Mailing Address - Country:US
Mailing Address - Phone:314-996-8139
Mailing Address - Fax:
Practice Address - Street 1:650 JOEL DR
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5318
Practice Address - Country:US
Practice Address - Phone:573-233-5911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-26
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190201572255A2300X
TN32952255A2300X
IL0960043992255A2300X
MO390200000X
KYTCA0992255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program