Provider Demographics
NPI:1730581513
Name:SHEPHERD, RYAN ANDREW (PAC)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:ANDREW
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 MEDICAL CENTER BLVD STE 350
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-7768
Mailing Address - Country:US
Mailing Address - Phone:678-312-2700
Mailing Address - Fax:678-312-2730
Practice Address - Street 1:2200 MEDICAL CENTER BLVD STE 350
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7768
Practice Address - Country:US
Practice Address - Phone:678-312-2700
Practice Address - Fax:678-312-2730
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12230363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant