Provider Demographics
NPI:1528467271
Name:MAYNARD, CRYSCILLA (PA-C)
Entity type:Individual
Prefix:
First Name:CRYSCILLA
Middle Name:
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8423 MARKET ST
Mailing Address - Street 2:STE 205
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-6778
Mailing Address - Country:US
Mailing Address - Phone:330-729-1934
Mailing Address - Fax:330-729-1861
Practice Address - Street 1:8423 MARKET ST
Practice Address - Street 2:STE 205
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-6778
Practice Address - Country:US
Practice Address - Phone:330-729-1933
Practice Address - Fax:330-729-1861
Is Sole Proprietor?:No
Enumeration Date:2014-08-19
Last Update Date:2017-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50004041363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0119669Medicaid
OHH456980Medicare UPIN