Provider Demographics
NPI:1154620227
Name:SHEPHERD, MARK M (PA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:M
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602373
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2373
Mailing Address - Country:US
Mailing Address - Phone:828-213-1994
Mailing Address - Fax:
Practice Address - Street 1:1 HOSPITAL DR
Practice Address - Street 2:SUITE 4200
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-4550
Practice Address - Country:US
Practice Address - Phone:828-213-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-15
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03466363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1154620227Medicaid
NC176H9OtherBCBS NC
NC1154620227Medicaid