Provider Demographics
NPI:1730529421
Name:SHEPHERD, MITCHELL T (PA-C)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:T
Last Name:SHEPHERD
Suffix:
Gender:M
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 1:1350 E 750 N
Mailing Address - Street 2:SUITE 1
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-4345
Mailing Address - Country:US
Mailing Address - Phone:801-850-4250
Mailing Address - Fax:
Practice Address - Street 1:1350 E 750 N
Practice Address - Street 2:SUITE 1
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-4345
Practice Address - Country:US
Practice Address - Phone:801-850-4250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5339107-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical