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NPI Code Detail

MEDICARE: MEGAN MARIE LIDTKE

MEDICARE: MEGAN MARIE LIDTKE
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant

General Provider Information

NPI Number : 1245194455
Entity Type Code : Individual
Provider Name (Legal Business Name) : MEGAN MARIE LIDTKE
Provider Business Mailing Address
First Line : 15914 LINNET ST NW
Second Line :
City : ANDOVER
State : MN
Zip : 55304-2563
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 4040 COON RAPIDS BLVD NW STE 120
Second Line :
City : COON RAPIDS
State : MN
Zip : 55433-4568
Country : US
Telephone Number : 763-427-9980
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/11/2025
Last Update Date : 12/11/2025

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