MEDICARE: SISLEY NG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PTL.0019419	CO
2	225100000X	Physical Therapist	13050	MN

General Provider Information

NPI Number	:	1104505668
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SISLEY NG

Provider Business Mailing Address
First Line	:	3484 SAVANNAH AVE
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-4579
Country	:	US
Telephone Number	:	651-235-4095
Fax Number	:

Provider Business Practice Location Address
First Line	:	3484 SAVANNAH AVE
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-4579
Country	:	US
Telephone Number	:	651-235-4095
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2023
Last Update Date	:	12/01/2025

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Directions to “ SISLEY NG ” Practice Location

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