Provider Demographics
NPI:1659318228
Name:SHEPHERD, OLE VERNI (PA)
Entity Type:Individual
Prefix:
First Name:OLE
Middle Name:VERNI
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 2 BOX 196
Mailing Address - Street 2:
Mailing Address - City:ST JAMES
Mailing Address - State:MN
Mailing Address - Zip Code:56081-9653
Mailing Address - Country:US
Mailing Address - Phone:507-327-7698
Mailing Address - Fax:
Practice Address - Street 1:710 S KENWOOD AVE
Practice Address - Street 2:
Practice Address - City:MOOSE LAKE
Practice Address - State:MN
Practice Address - Zip Code:55767-9405
Practice Address - Country:US
Practice Address - Phone:218-485-4481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1517-023363A00000X
MN8988363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN292820500Medicaid
WI41966500Medicaid
WI41966500Medicaid