Healthcare Provider Details

I. General information

NPI: 1699380550
Provider Name (Legal Business Name): MR. ALEXANDER THIEME SHEPPARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2020
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 CORNELL RD
LATHAM NY
12110-1491
US

IV. Provider business mailing address

950 DANBY RD STE 202F
ITHACA NY
14850-5663
US

V. Phone/Fax

Practice location:
  • Phone: 518-510-3100
  • Fax:
Mailing address:
  • Phone: 607-260-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: