Healthcare Provider Details

I. General information

NPI: 1477586162
Provider Name (Legal Business Name): STACIA S MUNN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS STACIA MARIE SANDERS

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 N RAYMOND ST
BOISE ID
83704-9251
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-6030
  • Fax: 208-367-6123
Mailing address:
  • Phone: 208-381-2222
  • Fax: 208-367-6123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMR-0870
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-10171
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: