Provider Demographics
NPI:1699443945
Name:O'LEARY, MEGAN JO
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:JO
Last Name:O'LEARY
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 1:9741 VINCENT AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55444-1015
Mailing Address - Country:US
Mailing Address - Phone:507-208-8819
Mailing Address - Fax:
Practice Address - Street 1:9400 ZANE AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-1814
Practice Address - Country:US
Practice Address - Phone:952-826-8475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 390200000X
MN1205353363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program