Basic Information
Provider Information
NPI: 1003013137
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BRANT
FirstName: MEGHAN
MiddleName: ELIZABETH
NamePrefix: MRS.
NameSuffix:  
Credential: PAC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: PETERSON
OtherFirstName: MEGHAN
OtherMiddleName: ELIZABETH
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential: PAC
OtherLastNameType: 1
Mailing Information
Address1: 2603 39TH AVE NE STE D-202
Address2:  
City: MINNEAPOLIS
State: MN
PostalCode: 554214372
CountryCode: US
TelephoneNumber: 6122132370
FaxNumber: 6125245571
Practice Location
Address1: 2603 39TH AVE NE STE D202
Address2:  
City: MINNEAPOLIS
State: MN
PostalCode: 554214372
CountryCode: US
TelephoneNumber: 6122132370
FaxNumber: 6125245571
Other Information
ProviderEnumerationDate: 07/02/2007
LastUpdateDate: 01/30/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 01/30/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363AM0700X MNY Physician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
363AM0700X4354WIN Physician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical

ID Information
IDTypeStateIssuerDescription
100301313705WI MEDICAID
75796700005MN MEDICAID


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