Provider Demographics
NPI:1760727937
Name:SHEPPARD, FREDERICK KNIGHT (DC)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:KNIGHT
Last Name:SHEPPARD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2649 BAY SETTLEMENT ROAD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311
Mailing Address - Country:US
Mailing Address - Phone:906-370-8335
Mailing Address - Fax:
Practice Address - Street 1:2649 BAY SETTLEMENT RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-7328
Practice Address - Country:US
Practice Address - Phone:906-370-8335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1883111NI0013X, 111NS0005X, 111NX0800X
MI2301005616111NI0013X, 111NS0005X, 111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
No111NI0013XChiropractic ProvidersChiropractorIndependent Medical Examiner
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIE30003847Medicaid