Healthcare Provider Details

I. General information

NPI: 1093759300
Provider Name (Legal Business Name): KIRSTIN ADELBERGER SHEPPERSON PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 12/19/2023
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6161 LAKE BRANDT RD UNIT B
GREENSBORO NC
27455-8415
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 336-643-5800
  • Fax: 336-643-7474
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number102125
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number102125
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: