Provider Demographics
NPI:1659734911
Name:THISTLE, MEGAN LOUISE (OD)
Entity type:Individual
Prefix:MS
First Name:MEGAN
Middle Name:LOUISE
Last Name:THISTLE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:878 W AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1461
Mailing Address - Country:US
Mailing Address - Phone:920-806-3005
Mailing Address - Fax:920-806-3004
Practice Address - Street 1:878 W AIRPORT RD
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1461
Practice Address - Country:US
Practice Address - Phone:920-806-3005
Practice Address - Fax:920-806-3004
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-03
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3507-35152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist