Basic Information
| Provider Information | |||||||||
| NPI: | 1205860798 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHUMWAY | ||||||||
| FirstName: | MAYNARD | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 GATES RD | ||||||||
| Address2: | STE 3 | ||||||||
| City: | VESTAL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6075847385 | ||||||||
| FaxNumber: | 6077721223 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 LOMOND CT | ||||||||
| Address2: | |||||||||
| City: | UTICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 135025950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152921264 | ||||||||
| FaxNumber: | 3152660385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 07/23/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 001412 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 03324334 | 05 | NY | MEDICAID |