Provider Demographics
NPI:1477586162
Name:MUNN, STACIA S (MD)
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:S
Last Name:MUNN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:STACIA
Other - Middle Name:MARIE
Other - Last Name:SANDERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:208-367-6123
Practice Address - Street 1:777 N RAYMOND ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9251
Practice Address - Country:US
Practice Address - Phone:208-367-6030
Practice Address - Fax:208-367-6123
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMR-0870207Q00000X
IDM-10171207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807491300Medicaid
ID1196072Medicare PIN
RES000Medicare UPIN