Provider Demographics
NPI:1457356305
Name:SANICOLA, SHAWN MICHAEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:MICHAEL
Last Name:SANICOLA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2835 N GRANDVIEW BLVD
Mailing Address - Street 2:STE 300
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-5591
Mailing Address - Country:US
Mailing Address - Phone:262-542-3779
Mailing Address - Fax:262-542-4428
Practice Address - Street 1:2835 N GRANDVIEW BLVD STE 300
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-5591
Practice Address - Country:US
Practice Address - Phone:262-542-3779
Practice Address - Fax:262-542-4428
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI883025213ES0103X, 213E00000X, 213ES0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1316994924OtherNPI GROUP
WI1457356305OtherINDIVIDUAL NPI
WI0220260001Medicare NSC
WI1316994924OtherNPI GROUP