Provider Demographics
NPI:1306204631
Name:SHEPHERD, DEXTER (NP)
Entity Type:Individual
Prefix:
First Name:DEXTER
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 BOONE RIDGE DR
Mailing Address - Street 2:STE 201
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-8000
Mailing Address - Country:US
Mailing Address - Phone:423-282-1480
Mailing Address - Fax:423-928-1353
Practice Address - Street 1:229 BART GREENE DR
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37615-4612
Practice Address - Country:US
Practice Address - Phone:423-946-0971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-01
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN174366363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily