Provider Demographics
NPI:1720612641
Name:MUNN, MICHAEL JOHN (APRN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:MUNN
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:293 NORMAN RD
Mailing Address - Street 2:
Mailing Address - City:KIRBYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65679-9332
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:33 GAGE DR
Practice Address - Street 2:
Practice Address - City:HOLLISTER
Practice Address - State:MO
Practice Address - Zip Code:65672-5862
Practice Address - Country:US
Practice Address - Phone:417-334-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-29
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE113103363L00000X
MO20211036122363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420103556Medicaid