Provider Demographics
NPI:1922093384
Name:SHEPARD, REBECCA C (PA-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:C
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:C
Other - Last Name:COATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:402 W MORROW RD
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-6549
Mailing Address - Country:US
Mailing Address - Phone:918-245-1328
Mailing Address - Fax:918-293-3181
Practice Address - Street 1:402 W MORROW RD
Practice Address - Street 2:
Practice Address - City:SAND SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74063-6549
Practice Address - Country:US
Practice Address - Phone:918-245-1328
Practice Address - Fax:918-293-3181
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA1291363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200024950BMedicaid
OK200024950AMedicaid
OK200024950AMedicaid