Basic Information
| Provider Information | |||||||||
| NPI: | 1902276355 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCNULTY | ||||||||
| FirstName: | GARRETT | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1808 W BELTLINE HWY | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537132334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082501497 | ||||||||
| FaxNumber: | 6082501384 | ||||||||
| Practice Location | |||||||||
| Address1: | 11051 N SHERMAN RD | ||||||||
| Address2: | |||||||||
| City: | EDGERTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535349002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088843354 | ||||||||
| FaxNumber: | 6088845024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2015 | ||||||||
| LastUpdateDate: | 12/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 64648-20 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1902276355 | 05 | WI | MEDICAID |