Healthcare Provider Details

I. General information

NPI: 1801264825
Provider Name (Legal Business Name): MEGAN R GRODAHL P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEGAN R DOLLEN

II. Dates (important events)

Enumeration Date: 09/08/2015
Last Update Date: 09/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1351 W MAIN ST
LAKE CITY IA
51449-1585
US

IV. Provider business mailing address

1301 W MAIN ST PO BOX 114
LAKE CITY IA
51449-1585
US

V. Phone/Fax

Practice location:
  • Phone: 712-464-7907
  • Fax: 712-464-7412
Mailing address:
  • Phone: 712-464-3171
  • Fax: 712-464-3269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number079586
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: