Provider Demographics
NPI:1336845908
Name:SHEPARD, ANTHONY TRAYVON
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:TRAYVON
Last Name:SHEPARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6060 SILVER LAKE RD APT 13G
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89506-1782
Mailing Address - Country:US
Mailing Address - Phone:775-303-6446
Mailing Address - Fax:
Practice Address - Street 1:6060 SILVER LAKE RD APT 13G
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89506-1782
Practice Address - Country:US
Practice Address - Phone:775-303-6446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0806091399163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV0806091399Medicaid