Basic Information
| Provider Information | |||||||||
| NPI: | 1730131335 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHEPARD | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 66308 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772666308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8325485076 | ||||||||
| FaxNumber: | 7135234897 | ||||||||
| Practice Location | |||||||||
| Address1: | 1415 CALIFORNIA ST | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770062602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8325485000 | ||||||||
| FaxNumber: | 7135234897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 07/25/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 661009 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 080462703 | 05 | TX | MEDICAID |