Provider Demographics
NPI:1760504559
Name:SHEPARDSON, PETER (RN)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:SHEPARDSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BOSTON MEDICAL CTR PL
Mailing Address - Street 2:SUITE 5108
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2908
Mailing Address - Country:US
Mailing Address - Phone:617-638-7062
Mailing Address - Fax:
Practice Address - Street 1:1 BOSTON MEDICAL CTR PL
Practice Address - Street 2:SUITE 5108
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2908
Practice Address - Country:US
Practice Address - Phone:617-638-7062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA214719163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1300881Medicaid
MA0300030OtherMBHP