Provider Demographics
NPI:1518941160
Name:PECKOSH, SEJAL S (PA)
Entity Type:Individual
Prefix:
First Name:SEJAL
Middle Name:S
Last Name:PECKOSH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SEJAL
Other - Middle Name:D
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:4194 LEXINGTON AVE N
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-6106
Practice Address - Country:US
Practice Address - Phone:651-483-5461
Practice Address - Fax:651-483-2155
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11604363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00709139OtherRR MEDICARE
CTQ33502Medicare UPIN