Provider Demographics
NPI:1356792642
Name:NELSON, MEGAN RAE (DPT, ATC)
Entity type:Individual
Prefix:DR
First Name:MEGAN
Middle Name:RAE
Last Name:NELSON
Suffix:
Gender:F
Credentials:DPT, ATC
Other - Prefix:DR
Other - First Name:MEGAN
Other - Middle Name:RAE
Other - Last Name:ROSCHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT, ATC
Mailing Address - Street 1:7825 3RD ST N
Mailing Address - Street 2:STE 105
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-5444
Mailing Address - Country:US
Mailing Address - Phone:952-835-4512
Mailing Address - Fax:888-425-0398
Practice Address - Street 1:7750 HARKNESS AVE S STE 109
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-2163
Practice Address - Country:US
Practice Address - Phone:952-835-4512
Practice Address - Fax:888-425-0398
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10296225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN150853OtherOPTUM PROVIDER ID