Provider Demographics
NPI:1720171994
Name:SHEPHERD, SANDRA LAUREN (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LAUREN
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 FORT MISSOULA RD STE 115
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7403
Mailing Address - Country:US
Mailing Address - Phone:406-541-9222
Mailing Address - Fax:406-541-9223
Practice Address - Street 1:2825 FORT MISSOULA RD STE 115
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7403
Practice Address - Country:US
Practice Address - Phone:406-541-9222
Practice Address - Fax:406-541-9223
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT11067207V00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I14731Medicare UPIN
011000445Medicare PIN