Provider Demographics
NPI:1316744618
Name:SHEPHERD, TYRA (CCMA)
Entity type:Individual
Prefix:MRS
First Name:TYRA
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:
Credentials:CCMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8245 E 96TH ST # 1057
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-1013
Mailing Address - Country:US
Mailing Address - Phone:317-707-6884
Mailing Address - Fax:
Practice Address - Street 1:5698 TEAK LN
Practice Address - Street 2:
Practice Address - City:MCCORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46055-0106
Practice Address - Country:US
Practice Address - Phone:317-313-7408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical