Provider Demographics
NPI:1669485165
Name:SHEPARD, MARY ALICE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:MD
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 65010
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98665-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2211 E MILL PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-4329
Practice Address - Country:US
Practice Address - Phone:360-418-6001
Practice Address - Fax:130-418-6008
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA MD00023639207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine