Basic Information
Provider Information | |||||||||
NPI: | 1255703336 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHEPHERD | ||||||||
FirstName: | ANGELA | ||||||||
MiddleName: | S | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 E LIBERTY ST | ||||||||
Address2: | SUITE 800 | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402021434 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6063307807 | ||||||||
FaxNumber: | 6063307825 | ||||||||
Practice Location | |||||||||
Address1: | 1401 HARRODSBURG RD | ||||||||
Address2: | SUITE C-100 | ||||||||
City: | LEXINGTON | ||||||||
State: | KY | ||||||||
PostalCode: | 405043751 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8592761966 | ||||||||
FaxNumber: | 8592762840 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/28/2015 | ||||||||
LastUpdateDate: | 01/21/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/21/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | TC406 | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.