Basic Information
Provider Information | |||||||||
NPI: | 1841869880 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHELDON | ||||||||
FirstName: | GREGORY | ||||||||
MiddleName: | ROBERT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT, ATC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7581 9TH ST N STE 100 | ||||||||
Address2: |   | ||||||||
City: | OAKDALE | ||||||||
State: | MN | ||||||||
PostalCode: | 551286635 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6517484338 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 146 LAKE ST N | ||||||||
Address2: |   | ||||||||
City: | FOREST LAKE | ||||||||
State: | MN | ||||||||
PostalCode: | 550252518 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512754706 | ||||||||
FaxNumber: | 6514648547 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2021 | ||||||||
LastUpdateDate: | 07/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 3200 | MN | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 225100000X | 12291 | MN | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.