Basic Information
Provider Information | |||||||||
NPI: | 1962069864 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAYNARD | ||||||||
FirstName: | ALLYSON | ||||||||
MiddleName: | CAROL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT, DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5430 SOUTHRIDGE CIR | ||||||||
Address2: |   | ||||||||
City: | WOODBURY | ||||||||
State: | MN | ||||||||
PostalCode: | 551295520 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9493512635 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 155 RADIO DR | ||||||||
Address2: |   | ||||||||
City: | WOODBURY | ||||||||
State: | MN | ||||||||
PostalCode: | 551252619 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9528318742 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/26/2019 | ||||||||
LastUpdateDate: | 08/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081S0010X | 4730 | MN | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine | 225100000X | 11489 | MN | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.