Provider Demographics
NPI:1992038962
Name:SHEPPARD, MONICA (PA)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-1212
Mailing Address - Country:US
Mailing Address - Phone:203-863-2003
Mailing Address - Fax:203-863-2025
Practice Address - Street 1:31 RIVER RD
Practice Address - Street 2:
Practice Address - City:COS COB
Practice Address - State:CT
Practice Address - Zip Code:06807-2152
Practice Address - Country:US
Practice Address - Phone:203-863-2003
Practice Address - Fax:203-863-2025
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-09
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013459363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWZWYR1Medicare PIN
CTC03778Medicare PIN