Provider Demographics
NPI:1164706214
Name:SHEPARDSON, MEGAN A (LMP)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:A
Last Name:SHEPARDSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14948 PRAIRIE VISTA LOOP
Mailing Address - Street 2:
Mailing Address - City:YELM
Mailing Address - State:WA
Mailing Address - Zip Code:98597-8722
Mailing Address - Country:US
Mailing Address - Phone:718-751-6424
Mailing Address - Fax:
Practice Address - Street 1:14948 PRAIRIE VISTA LOOP
Practice Address - Street 2:
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597-8722
Practice Address - Country:US
Practice Address - Phone:718-751-6424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60240912172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist