Provider Demographics
NPI:1831173079
Name:SHEPARD, BEVERLY (NP)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1571 WASHINGTON ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-9304
Mailing Address - Country:US
Mailing Address - Phone:315-782-1650
Mailing Address - Fax:315-788-8547
Practice Address - Street 1:1571 WASHINGTON ST
Practice Address - Street 2:SUITE 201
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-9304
Practice Address - Country:US
Practice Address - Phone:315-782-1650
Practice Address - Fax:315-788-8547
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF330120363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02284366Medicaid
NY02284366Medicaid
DD1596Medicare PIN