Provider Demographics
NPI:1952330763
Name:SHEPHERD, DANIEL G (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:G
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 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4302
Mailing Address - Country:US
Mailing Address - Phone:562-499-6191
Mailing Address - Fax:562-499-6171
Practice Address - Street 1:44216 10TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-4134
Practice Address - Country:US
Practice Address - Phone:661-723-7416
Practice Address - Fax:661-723-9975
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13168207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA13168OtherMEDI CAL
CAPA13168Medicaid
CAPA13168Medicaid
CABE931ZMedicare PIN
CABE931TMedicare PIN
CABE931XMedicare PIN
CABE931UMedicare PIN
CAPA13168OtherMEDI CAL
S64208Medicare UPIN
CABE931WMedicare PIN
CABE931SMedicare PIN