Basic Information
| Provider Information | |||||||||
| NPI: | 1073590071 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIELD | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | WYATT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT. 453 PO BOX 1000 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285752625 | ||||||||
| FaxNumber: | 8283502174 | ||||||||
| Practice Location | |||||||||
| Address1: | 1144 PROFESSIONAL DR | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231853330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572590443 | ||||||||
| FaxNumber: | 7572590450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2005 | ||||||||
| LastUpdateDate: | 06/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 0101049643 | VA | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 1073590071 | 05 | VA | MEDICAID | 00Y225A01 | 01 | VA | MEDICARE PTAN | OTHER |