Provider Demographics
NPI:1093435448
Name:SMITH, SHEVON BORDE
Entity type:Individual
Prefix:
First Name:SHEVON
Middle Name:BORDE
Last Name:SMITH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 WARWICK RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-6022
Mailing Address - Country:US
Mailing Address - Phone:215-436-7842
Mailing Address - Fax:
Practice Address - Street 1:1701 JOHN TIPTON BLVD
Practice Address - Street 2:
Practice Address - City:PENNSAUKEN
Practice Address - State:NJ
Practice Address - Zip Code:08110-1405
Practice Address - Country:US
Practice Address - Phone:215-436-7842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2025-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP029315363LF0000X
NJ26NJ15083000363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily