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NPI Code Detail

MEDICARE: MEGANNE GOURLEY PA-C, ATC

MEDICARE: MEGANNE GOURLEY PA-C, ATC
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
1363AS0400XSurgical Physician Assistant1503203KS
2363A00000XPhysician Assistant085-006084IL
3363A00000XPhysician Assistant12581MN

General Provider Information

NPI Number : 1275646978
Entity Type Code : Individual
Provider Name (Legal Business Name) : MEGANNE GOURLEY PA-C, ATC
Provider Business Mailing Address
First Line : 2925 CHICAGO AVE
Second Line :
City : MINNEAPOLIS
State : MN
Zip : 55407-1321
Country : US
Telephone Number : 612-262-5000
Fax Number :
Provider Business Practice Location Address
First Line : 100 STATE AVE
Second Line :
City : FARIBAULT
State : MN
Zip : 55021-6337
Country : US
Telephone Number : 507-334-3921
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/16/2006
Last Update Date : 12/17/2025

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