Provider Demographics
NPI:1811091598
Name:SHEPHERD, BRETT A
Entity type:Individual
Prefix:MR
First Name:BRETT
Middle Name:A
Last Name:SHEPHERD
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 1:628 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-3409
Mailing Address - Country:US
Mailing Address - Phone:252-975-4100
Mailing Address - Fax:252-948-4829
Practice Address - Street 1:628 E 12TH ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-3409
Practice Address - Country:US
Practice Address - Phone:252-975-4100
Practice Address - Fax:252-948-4829
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC053053367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered