Provider Demographics
NPI:1831678523
Name:GAVRILESCU, SHAWN ROBERT
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:ROBERT
Last Name:GAVRILESCU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3572 N FAUST LAKE RD
Mailing Address - Street 2:
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501-9310
Mailing Address - Country:US
Mailing Address - Phone:651-497-8219
Mailing Address - Fax:
Practice Address - Street 1:900 BOYCE DR
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-3835
Practice Address - Country:US
Practice Address - Phone:715-365-6832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2424208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation