Basic Information
| Provider Information | |||||||||
| NPI: | 1720612641 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUNN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 802843 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641802843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178753000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 33 GAGE DR | ||||||||
| Address2: | |||||||||
| City: | HOLLISTER | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656725862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173348300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/29/2020 | ||||||||
| LastUpdateDate: | 09/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 113103 | NE | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 20211036122 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 420103556 | 05 | MO | MEDICAID |