Provider Demographics
NPI:1013242197
Name:SIS, MEGAN MARIE (OD, MS, FAAO)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:MARIE
Last Name:SIS
Suffix:
Gender:F
Credentials:OD, MS, FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12170 ABERDEEN ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-4716
Mailing Address - Country:US
Mailing Address - Phone:763-757-7000
Mailing Address - Fax:763-757-3328
Practice Address - Street 1:12170 ABERDEEN ST NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-4716
Practice Address - Country:US
Practice Address - Phone:763-757-7000
Practice Address - Fax:763-757-3328
Is Sole Proprietor?:No
Enumeration Date:2009-10-07
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002668152W00000X
MN3315152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3315OtherLICENSE
PAOEG002668OtherLICENSE