| NPI |
1184058273 |
The State code in the location of the provider
being identified. |
| Entity Type Code |
1 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
| Provider Last Name Legal Name |
SHEPARD |
The country code in the location address of the provider being identified. |
| Provider First Name |
TREVOR |
The first name of the provider, if the provider
is an individual. |
| Provider Middle Name |
B |
The middle name of the provider, if the provider
is an individual. |
| Provider Name Prefix Text |
MR. |
The date the provider was assigned a unique identifier (assigned an NPI). |
| Provider First Line Business Practice Location Address |
390 40TH ST |
The date that a record was last updated or changed. |
| Provider Business Practice Location Address City Name |
OAKLAND |
The code designating the provider’s gender if the provider is a person. |
| Provider Business Practice Location Address State Name |
CA |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Provider Business Practice Location Address Postal Code |
946092633 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
| Provider Business Practice Location Address Country Code If outside U S |
US |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
| Provider Business Practice Location Address Telephone Number |
5106535040 |
|
| Provider Business Practice Location Address Fax Number |
5106536475 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Provider Enumeration Date |
8/26/2013 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Last Update Date |
8/26/2013 |
|
| Provider Gender Code |
M |
The code designating the provider’s gender if the provider is a person. |
| Healthcare Provider Taxonomy Code 1 |
101YM0800X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
| Is Sole Proprietor |
Y |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |