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1386636553

NPI Code Detail

MEDICARE: NICOLE D SILLOWAY PA-C

MEDICARE: NICOLE D SILLOWAY PA-C

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	363A00000X	Physician Assistant
2	363A00000X	Physician Assistant	9401	MN
3	363AM0700X	Medical Physician Assistant	9401	MN
4	363AM0700X	Medical Physician Assistant	1954	WI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	003756125	OTHER	WI	MEDICARE #

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386636553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE D SILLOWAY PA-C

Provider Business Mailing Address
First Line	:	7200 VALLEY CREEK PLAZA
Second Line	:
City	:	WOODBURY
State	:	MN
Zip	:	55125-2265
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2165 WHITE BEAR AVE N
Second Line	:
City	:	MAPLEWOOD
State	:	MN
Zip	:	55109-2707
Country	:	US
Telephone Number	:	651-523-9800
Fax Number	:

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

Provider Enumeration Date	:	08/16/2005
Last Update Date	:	11/04/2025

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Directions to “ NICOLE D SILLOWAY PA-C” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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