Provider Demographics
NPI:1346349297
Name:SHEPHERD, CYNTHIA J (PA-C)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:J
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 841656
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1656
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:5414 S BROADWAY
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1335
Practice Address - Country:US
Practice Address - Phone:903-581-1601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TXPA00873207R00000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-0818167-015OtherTRICARE
TX298380104Medicaid
TX75-2616977-001OtherTRICARE
TX87N530OtherBCBS
TXP01762496OtherRAIL ROAD MEDICARE
TX75-0818167-044OtherTRICARE
TX75-2616977-002OtherTRICARE
TX75-2616977-028OtherTRICARE
TXP01761917OtherRAIL ROAD MEDICARE
TX75-2616977-129OtherTRICARE
TX298380106Medicaid
TX298380105Medicaid
TX75-0818167-022OtherTRICARE
TX75-0818167-048OtherTRICARE
TX298380107Medicaid
TX75-1976930-005OtherTRICARE
TX543275YS6VMedicare PIN
TX543277YS6PMedicare PIN
TX75-0818167-022OtherTRICARE
TX75-0818167-048OtherTRICARE
TX75-2616977-002OtherTRICARE
TXP01761917OtherRAIL ROAD MEDICARE