Provider Demographics
NPI:1902989825
Name:SHEPARD, STEPHEN H (PA)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:H
Last Name:SHEPARD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 848789
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-8789
Mailing Address - Country:US
Mailing Address - Phone:757-221-7111
Mailing Address - Fax:757-221-8085
Practice Address - Street 1:222 S HERLONG AVE
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1158
Practice Address - Country:US
Practice Address - Phone:803-329-6849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA344363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQM0528Medicaid
SCP27075Medicare UPIN