Provider Demographics
NPI:1558425967
Name:CANTWELL, REBECCA (PA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:CANTWELL
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 1:500 OSBORNE RD NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-2765
Mailing Address - Country:US
Mailing Address - Phone:763-236-2180
Mailing Address - Fax:763-236-2067
Practice Address - Street 1:500 OSBORNE RD NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-2765
Practice Address - Country:US
Practice Address - Phone:763-236-2180
Practice Address - Fax:763-236-2067
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1369363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1369OtherSTATE MEDICAL LICENSE
OH50.001798OtherSTATE OF OHIO MEDICAL BOA