Provider Demographics
NPI:1659339844
Name:SHEPARD, SCOTT B (PA-C)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:B
Last Name:SHEPARD
Suffix:
Gender:M
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 1:1072 X RAY DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-7488
Mailing Address - Country:US
Mailing Address - Phone:704-671-1094
Mailing Address - Fax:704-671-1095
Practice Address - Street 1:105 DELTA PARK DR STE B
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3575
Practice Address - Country:US
Practice Address - Phone:704-484-0464
Practice Address - Fax:704-482-0308
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA.9104640363A00000X
SC430363A00000X
NC001011979363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009450700Medicaid