Provider Demographics
NPI:1790437614
Name:SHEPHERD, DAVID JACKSON (PA-C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JACKSON
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 GOODYS LN
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-1914
Mailing Address - Country:US
Mailing Address - Phone:865-251-1800
Mailing Address - Fax:
Practice Address - Street 1:1932 ALCOA HWY BLDG C
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1527
Practice Address - Country:US
Practice Address - Phone:865-524-1869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-21
Last Update Date:2022-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN5021363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program