Provider Demographics
NPI:1205340247
Name:SHEPHERD, JUSTIN (PA-C)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICH SQUARE
Mailing Address - State:NC
Mailing Address - Zip Code:27869-9582
Mailing Address - Country:US
Mailing Address - Phone:252-539-2082
Mailing Address - Fax:
Practice Address - Street 1:200 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RICH SQUARE
Practice Address - State:NC
Practice Address - Zip Code:27869
Practice Address - Country:US
Practice Address - Phone:252-539-2082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-29
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07726363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant