Provider Demographics
NPI:1386981090
Name:SHEPPARD, JOHN JOSEPH (PA-C)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:JOSEPH
Last Name:SHEPPARD
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 1:42 DEANE ST
Mailing Address - Street 2:
Mailing Address - City:WADING RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11792-1805
Mailing Address - Country:US
Mailing Address - Phone:631-456-9748
Mailing Address - Fax:
Practice Address - Street 1:42 DEANE ST
Practice Address - Street 2:
Practice Address - City:WADING RIVER
Practice Address - State:NY
Practice Address - Zip Code:11792-1805
Practice Address - Country:US
Practice Address - Phone:631-456-9748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016308-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical