Basic Information
| Provider Information | |||||||||
| NPI: | 1295929735 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OPSAHL | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REDISKE | ||||||||
| OtherFirstName: | MEGAN | ||||||||
| OtherMiddleName: | JEAN | ||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1304 W MEDICINE LAKE DR | ||||||||
| Address2: | #208 | ||||||||
| City: | MEDICINE LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554414860 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4080 W BROADWAY AVE | ||||||||
| Address2: | #300 | ||||||||
| City: | ROBBINSDALE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554225604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635330541 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2007 | ||||||||
| LastUpdateDate: | 08/28/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 7997 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.