Provider Demographics
NPI:1962487512
Name:MUNSON, NATHAN DARYL (MD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:DARYL
Last Name:MUNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 117
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54912-0117
Mailing Address - Country:US
Mailing Address - Phone:920-739-5642
Mailing Address - Fax:920-968-0259
Practice Address - Street 1:900 E GRANT ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-3487
Practice Address - Country:US
Practice Address - Phone:920-738-6340
Practice Address - Fax:920-738-6435
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME935302085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000745440Medicare PIN