Provider Demographics
NPI:1841869880
Name:SHELDON, GREGORY ROBERT (PT, ATC)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:ROBERT
Last Name:SHELDON
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 COUNTY ROAD C W
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-2501
Mailing Address - Country:US
Mailing Address - Phone:651-409-3081
Mailing Address - Fax:
Practice Address - Street 1:2130 COUNTY ROAD C W
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-2501
Practice Address - Country:US
Practice Address - Phone:651-409-3081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-23
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12291225100000X
MN32002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty