Provider Demographics
NPI:1528033149
Name:MARINELLO, SHERRY M (PA)
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:M
Last Name:MARINELLO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S
Mailing Address - Street 2:MS 21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15245 BLUEBIRD ST NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-3538
Practice Address - Country:US
Practice Address - Phone:763-587-4600
Practice Address - Fax:763-587-4615
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN9433363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN035742100Medicaid
MN035742100Medicaid
970001461Medicare ID - Type Unspecified