Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 3315 | MN |
N | 152W00000X | Optometrist | OEG002668 | PA |
N | 152WV0400X | Optomitrist - Vision Therapist | 3315 | MN |
NPI | 1013242197 |
---|---|
Provider Name | Megan Marie Sis |
First Address | Blaine, MN 55449-4716 |
Second Address | Blaine, MN 55449-4716 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/10/2009 |
Last Update Date | 11/07/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
3315 | LICENSE (01) | MN |
OEG002668 | LICENSE (01) | PA |