Provider Demographics
NPI:1861474504
Name:STONE, SHEPARD BRUCE (PAC)
Entity Type:Individual
Prefix:
First Name:SHEPARD
Middle Name:BRUCE
Last Name:STONE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 YORK ST
Mailing Address - Street 2:YNHH TOMPKINS BUILDING, 3RD FL
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3220
Mailing Address - Country:US
Mailing Address - Phone:203-785-2802
Mailing Address - Fax:203-785-6664
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:YNHH TOMPKINS BUILDING, 3RD FL
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-785-2802
Practice Address - Fax:203-785-6664
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000045363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT970001469Medicare ID - Type Unspecified
Q02464Medicare UPIN