Provider Demographics
NPI:1942266911
Name:SHEPHERD, DAVID W (CRNA, MSN)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:W
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:CRNA, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 STONEY CREEK CT
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:IN
Mailing Address - Zip Code:46714-9396
Mailing Address - Country:US
Mailing Address - Phone:260-824-8105
Mailing Address - Fax:
Practice Address - Street 1:303 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:IN
Practice Address - Zip Code:46714-2503
Practice Address - Country:US
Practice Address - Phone:260-824-3210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28100574A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100268120AMedicaid
INP26264Medicare UPIN
IN100268120AMedicaid