Provider Demographics
NPI:1043252299
Name:SHEPHERD, SHELLIE DIANE (PA-C)
Entity type:Individual
Prefix:
First Name:SHELLIE
Middle Name:DIANE
Last Name:SHEPHERD
Suffix:
Gender:F
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 1:12608 SOUTH FWY STE 140
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-8435
Mailing Address - Country:US
Mailing Address - Phone:817-295-7214
Mailing Address - Fax:817-295-7062
Practice Address - Street 1:12608 SOUTH FWY STE 140
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-8435
Practice Address - Country:US
Practice Address - Phone:817-295-7214
Practice Address - Fax:817-295-7062
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04151363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00175459Medicare ID - Type UnspecifiedRAILROAD MEDICARE
TXQ26701Medicare UPIN
TX8C7115Medicare ID - Type Unspecified