Provider Demographics
NPI:1184721656
Name:CAPELLO, ROBERT (PA-C)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:CAPELLO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 28900
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54324-0900
Mailing Address - Country:US
Mailing Address - Phone:920-490-9046
Mailing Address - Fax:920-405-5388
Practice Address - Street 1:1111 BAYSHORE DR
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-5548
Practice Address - Country:US
Practice Address - Phone:920-682-6376
Practice Address - Fax:920-652-0115
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-003171207P00000X
IL085003171363A00000X, 363AS0400X
OH50.004410363A00000X
WI3036363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1184721656Medicaid
WI71460Medicaid
OH0145029Medicaid
WI1184721656Medicaid
OHH463542Medicare PIN
WI71460Medicaid