Provider Demographics
NPI:1679234330
Name:SHEPHERD, EZEKIEL GRANT
Entity type:Individual
Prefix:
First Name:EZEKIEL
Middle Name:GRANT
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 KEITH WEATHERS RD
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-7477
Mailing Address - Country:US
Mailing Address - Phone:336-466-3201
Mailing Address - Fax:
Practice Address - Street 1:100 CORNERSTONE DR
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27519-8453
Practice Address - Country:US
Practice Address - Phone:919-650-3660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-05
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant