Provider Demographics
NPI:1396705174
Name:SHEPARD, STEPHANIE ANNE (PA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANNE
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:ANNE
Other - Last Name:SHEPARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 37174
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3174
Mailing Address - Country:US
Mailing Address - Phone:571-423-5699
Mailing Address - Fax:571-423-5698
Practice Address - Street 1:8260 WILLOW OAKS CORPORATE DR STE 650
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4531
Practice Address - Country:US
Practice Address - Phone:703-776-2000
Practice Address - Fax:571-665-6797
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18335363A00000X
NC0010-01115363AM0700X
VA0110005117363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical