Provider Demographics
NPI:1245194455
Name:LIDTKE, MEGAN MARIE
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:MARIE
Last Name:LIDTKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15914 LINNET ST NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-2563
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4040 COON RAPIDS BLVD NW STE 120
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-4568
Practice Address - Country:US
Practice Address - Phone:763-427-9980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-12-11
Last Update Date:2025-12-11
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant