Healthcare Provider Details

I. General information

NPI: 1437541471
Provider Name (Legal Business Name): STEPHEN ANDREW SHEPRO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2015
Last Update Date: 09/03/2021
Certification Date: 09/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 RUFUS LN
POLSON MT
59860-8903
US

IV. Provider business mailing address

2740 SOUTH AVE W STE 101
MISSOULA MT
59804-5137
US

V. Phone/Fax

Practice location:
  • Phone: 406-883-2555
  • Fax: 406-883-2559
Mailing address:
  • Phone: 406-728-6101
  • Fax: 406-721-3278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number51146
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number51146
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: