Provider Demographics
NPI:1689351223
Name:SHEPHERD, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4499 US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-5409
Mailing Address - Country:US
Mailing Address - Phone:321-266-7123
Mailing Address - Fax:
Practice Address - Street 1:1775 W HIBISCUS BLVD STE 215
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2627
Practice Address - Country:US
Practice Address - Phone:321-837-3820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-04
Last Update Date:2023-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant