Provider Demographics
NPI:1154733699
Name:ROSSALL, SARAH RAE (MPA, PA-C)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:RAE
Last Name:ROSSALL
Suffix:
Gender:F
Credentials:MPA, PA-C
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:RAE
Other - Last Name:O'CONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4240 PARK GLEN RD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5427
Mailing Address - Country:US
Mailing Address - Phone:612-925-6033
Mailing Address - Fax:612-925-8496
Practice Address - Street 1:4027 COUNTY ROAD 25
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416
Practice Address - Country:US
Practice Address - Phone:612-925-6033
Practice Address - Fax:612-925-8496
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3302-23363AM0700X
MN12602363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400198956Medicare PIN