Provider Demographics
NPI:1417913096
Name:SHEPPARD, MARY T (PNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 MAIN ST FL 5
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1009
Mailing Address - Country:US
Mailing Address - Phone:716-323-0110
Mailing Address - Fax:716-332-0296
Practice Address - Street 1:1001 MAIN ST FL 4
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1009
Practice Address - Country:US
Practice Address - Phone:716-323-0110
Practice Address - Fax:716-323-0296
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF380546363LP0200X
NY289921363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02344723Medicaid
071112000039OtherFIDELIS
080407000110OtherFIDELIS
RA5109Medicare ID - Type Unspecified
NY02344723Medicaid