Provider Demographics
NPI:1801264825
Name:GRODAHL, MEGAN R (PA)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:R
Last Name:GRODAHL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:R
Other - Last Name:DOLLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1301 W MAIN ST
Mailing Address - Street 2:PO BOX 114
Mailing Address - City:LAKE CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51449-1585
Mailing Address - Country:US
Mailing Address - Phone:712-464-3171
Mailing Address - Fax:712-464-3269
Practice Address - Street 1:1351 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:IA
Practice Address - Zip Code:51449-1585
Practice Address - Country:US
Practice Address - Phone:712-464-7907
Practice Address - Fax:712-464-7412
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA079586363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant