Provider Demographics
NPI:1891098943
Name:SHEPPARD, ELIZABETH ANNE (PA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANNE
Other - Last Name:BALCER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-9528
Mailing Address - Fax:
Practice Address - Street 1:8725 N WICKHAM RD STE 202
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-2240
Practice Address - Country:US
Practice Address - Phone:321-434-9528
Practice Address - Fax:321-434-9529
Is Sole Proprietor?:No
Enumeration Date:2010-12-13
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105602363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLNR566OtherFL MEDICARE
FL003181500Medicaid
FLPA9105602OtherLICENSE