Provider Demographics
NPI:1396707311
Name:SHEPHERD, VICTORIA STORM (PA)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:STORM
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 391405
Mailing Address - Street 2:
Mailing Address - City:SOLON
Mailing Address - State:OH
Mailing Address - Zip Code:44139-8405
Mailing Address - Country:US
Mailing Address - Phone:216-496-4433
Mailing Address - Fax:440-834-1902
Practice Address - Street 1:4180 WARRENSVILLE CENTER RD
Practice Address - Street 2:120
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-7024
Practice Address - Country:US
Practice Address - Phone:440-834-1833
Practice Address - Fax:440-834-1902
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH50001447363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH50001447OtherLICENSE
OH9357511OtherMEDICARE GROUP
OH50001447OtherLICENSE