Provider Demographics
NPI:1225142417
Name:SHEPARD-MARDOCCO, ROBERTA LEE (NP)
Entity Type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:LEE
Last Name:SHEPARD-MARDOCCO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:BOBBIE
Other - Middle Name:
Other - Last Name:SHEPARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:2122 N CRAYCROFT RD
Mailing Address - Street 2:#112
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2849
Mailing Address - Country:US
Mailing Address - Phone:520-791-0100
Mailing Address - Fax:520-791-0101
Practice Address - Street 1:4041 S MCCLINTOCK DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-5879
Practice Address - Country:US
Practice Address - Phone:520-233-7111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN036763363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health