Provider Demographics
NPI:1265475388
Name:SHEPHERD, SCOTT (CRNA)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 S GARNETT RD
Mailing Address - Street 2:STE 300
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-5229
Mailing Address - Country:US
Mailing Address - Phone:918-664-9892
Mailing Address - Fax:918-664-2521
Practice Address - Street 1:3215 N NORTHHILLS BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4424
Practice Address - Country:US
Practice Address - Phone:918-664-9892
Practice Address - Fax:918-664-2521
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC01510367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200051950AMedicaid
AR157034001Medicaid
AR771003601OtherARKANSAS BREASTCARE
AR771003601OtherARKANSAS BREASTCARE
AR5Y308Medicare PIN
OK200051950AMedicaid