Provider Demographics
NPI:1659658185
Name:SHEPPARD, MELANIE TOMEKO (PA)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:TOMEKO
Last Name:SHEPPARD
Suffix:
Gender:F
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:PO BOX 1245
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-1245
Mailing Address - Country:US
Mailing Address - Phone:803-395-4497
Mailing Address - Fax:803-536-0998
Practice Address - Street 1:1619 CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-4939
Practice Address - Country:US
Practice Address - Phone:803-531-7474
Practice Address - Fax:803-531-7457
Is Sole Proprietor?:No
Enumeration Date:2011-11-11
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1727363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA7271Medicare UPIN
SC5677Medicare PIN