Provider Demographics
NPI:1871699017
Name:SHEPARD, WAYNE H
Entity type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:H
Last Name:SHEPARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23414 NE 139TH LOOP
Mailing Address - Street 2:
Mailing Address - City:BRUSH PRAIRIE
Mailing Address - State:WA
Mailing Address - Zip Code:98606-9624
Mailing Address - Country:US
Mailing Address - Phone:360-896-5153
Mailing Address - Fax:
Practice Address - Street 1:12607 SE MILL PLAIN BLVD
Practice Address - Street 2:CASCADE PARK MEDICAL OFFICE
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-6055
Practice Address - Country:US
Practice Address - Phone:360-418-6001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADO00001507156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician