Basic Information
| Provider Information | |||||||||
| NPI: | 1831148931 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAYNOR | ||||||||
| FirstName: | KENRIC | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | M.D., M.P.H. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 129 HUCKLEBERRY DR | ||||||||
| Address2: | |||||||||
| City: | DURYEA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 186421153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708267300 | ||||||||
| FaxNumber: | 5708195647 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 E MOUNTAIN DR | ||||||||
| Address2: | |||||||||
| City: | WILKES BARRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187110027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708267300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 08/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | D62818 | MD | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 408307500 | 05 | MD | MEDICAID |