Provider Demographics
NPI:1154386001
Name:CAVALLARO, SHEILA M (PAC)
Entity type:Individual
Prefix:
First Name:SHEILA
Middle Name:M
Last Name:CAVALLARO
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20520 KEOKUK AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-6085
Mailing Address - Country:US
Mailing Address - Phone:952-469-5033
Mailing Address - Fax:952-469-5069
Practice Address - Street 1:20520 KEOKUK AVE STE 104
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-6085
Practice Address - Country:US
Practice Address - Phone:952-469-5033
Practice Address - Fax:952-469-5069
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MN9897207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0119269OtherSELECT CARE
MN1042141OtherPREFERRED ONE
MN132409OtherUCARE
MN352L5BEOtherBLUES
MN0119269OtherMEDICA
MN231912800Medicaid
MNHP47685OtherGROUP HEALTH
MN970001997Medicare ID - Type UnspecifiedMEDICARE